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Volume I: 
Executive Summary 



Report of the 
Secretary's Task 
Force on 




Black & 

Minority 

Health 



Margaret M. Heckler 

Secretary 



U.S. Department of Health and 
Human Services 




Volumel: J^l ^ _ i? J.1^ ^ (^W\0D9W 

Executive Summary 



Report of the 
Secretary's Task 
Force on 



Black & 

Minority 

Health 



Margaret M. Heckler 

Secretary 



U.S. Department of Health and 
Human Services 

August 1985 



SECRETARY'S TASK FORCE ON BLACK AND MINORITY HEALTH 



MEMBERS 



Thomas E. Malone, Ph.D., Chairperson 
Katrina W. Johnson, Ph.D., Study Director 



Wendy Baldwin, Ph.D 

Betty Lou Dotson, J.D. 

Manning Feinleib, M.D., Dr.P.H. 

William T. Friedewald, M.D. 

Robert Graham, M.D. 

M. Gene Handelsraan 

Jane E. Henney, M.D. 

Donald R. Hopkins, M.D. 

Stephanie Lee-Miller 



Jaime Manzano 

J. Michael McGinnis , M.D. 

Mark Novitch, M.D. 

Clarice D. Reid, M.D. 

Everett R. Rhoades , M.D. 

William A. Robinson, M.D. , 

James L. Scott 

Robert L. Trachtenberg 

T. Franklin Williams, M.D. 



M.P.H. 



ALTERNATES 



Shirley P. Bagley, M.S. 
Claudia Baquet, M.D. , M, 
Howard M. Bennett 
Cheryl Damberg, M.P.H. 
Mary Ann Danello, Ph.D. 
Jacob Feldman, Ph.D. 
Marilyn Gaston, M.D. 
George Hardy, M.D. 
John H. Kelso 



P.H. 



James A. Kissko 
Robert C. Kreuzburg, M.D. 
Barbara J. Lake 
Patricia L. Mackey, J.D. 
Delores Parron, Ph.D. 
Gerald H. Payne, M.D. 
Caroline I. Reuter 
Clay Simpson, Jr., Ph.D. 
Ronald J. Wylie 



For sale hy the Superintendent o£ Documents, U.S. Government Printing Office 
Wasliincton. D.C. 20402 



TABLE OF CONTENTS 

Letter of Transmittal vii 

Secretary's Foreword and Charge to the Task Force ix 

Tables and Figures xi 

INTRODUCTION AND OVERVIEW 1 

RECOMMENDATIONS OF THE TASK FORCE 

Health Information and Education 9 

Health Services 15 

Health Professions Development 21 

Cooperative Efforts 25 

Data Development 31 

Research Agenda 37 

ACCOUNTING FOR THE HEALTH STATUS DISPARITY 

Social Characteristics of Minority Populations 47 

Mortality and Morbidity Indicators 63 

Subcommittee Summary Reports 

Cancer 87 

Cardiovascular and Cerebrovascular Diseases 107 

Chemical Dependency 129 

Diabetes 149 

Homicide, Suicide, and Unintentional Injuries .... 157 

Infant Mortality and Low Birthweight 171 

Health Services and Resources for Minorities 187 



Inventory of DHHS Program Efforts 197 

Survey of Non-Federal Organizations 205 

APPENDIX 

Task Force Members and Alternates 215 

Task Force Subcommittees 219 

Task Force Staff 227 

Commissioned Papers 229 

Acknowledgments 237 

Key to Abbreviations 239 



^«S!«l.„.,^ 



4 



DEPARTMENT OF HEALTH AND HUMAN SERVICES 1?®'^/°'^.?," -^ ^ uu 

Black and Minonty Health 



The Honorable Margaret M. Heckler 
Secretary, Department of Health 

and Human Services 
Washington, D.C. 20201 

Dear Madam Secretary: 



National Institutes of Health 
Bethesda, Maryland 20205 
(301) 496^177 



On behalf of the Task Force on Black and Minority Health, I am 
pleased to submit the report and recommendations of the Task Force for 
your review and consideration. The report consists of an executive 
summary volume presenting our major findings and recommendations , and 
additional volumes containing extensive background information and 
analyses supporting and extending the executive summary. These will be 
extremely useful to those who wish to become familiar in greater depth 
with selected aspects of the issues we have analyzed. 

I believe this report is a landmark effort in analyzing and 
synthesizing the present state of knowledge of the major factors that 
contribute to the health status of Blacks, Hispanics, Asian/Pacific 
Islanders, and Native Americans. It represents the first time the 
Department of Health and Human Services (DHHS) has consolidated minority 
health issues into one report. This report should serve not only as a 
standard resource for departmentwide strategy, but as the generating 
force for an accelerated national assault on the persistent health 
disparities which led you to establish the Task Force a little more than 
a year ago. 

It would be a disservice to the Task Force members, staff and 
consultants who worked so diligently on this project during the past 
year, to understate the complexity of the task we undertook. The issues 
identified during our deliberations and presented in this report are of 
major importance, but must not be regarded as the final word on the 
subject. Just as individual well-being is not static, the health needs 
of minority populations are changing. They are influenced by a diverse 
set of factors of which disease is but one aspect. The report, then, 
must continue to be updated and revised as new data and information 
become available. 

In accordance with your charge, we have examined the impact of a 
broad range of behavioral, societal, and health care issues on the 
current departmental program areas. Our recommendations are consistent 
with the objectives for the Nation in disease prevention and health 
promotion for the year 1990. The six topics we have identified as 
priority areas merit intensive action and study in themselves, as do 
various issues such as nutrition and development of health professionals 
that cut across all health problem areas. We encourage the Department 
to continue to take the lead in implementing such activities. 



Page 2 - The Honorable Margaret M. Heckler 



The Task Force accomplished this monumental effort during the 
course of one year only by mobilization of resources across the DHHS 
agencies and by the dedicated contribution of all the Department staff 
who served on Subcommittees, responded to our inquiries, and provided 
supporting documentation necessary for us to arrive at these conclusions 
and recommendations. In addition, many health professionals and 
researchers outside the Federal government contributed to the Task Force 
efforts by educating the Task Force members, providing information, and 
enhancing our knowledge in ways we could not have accomplished on our 
own in the time available to us. 

The report has already had an extraordinarily beneficial effect. 
The levels of awareness and sensitivity to the issues surrounding 
minority health have been greatly heightened among the individuals 
serving on the Task Force and through them, within the agencies, 
divisions, and programs of the Department. Many of the specific 
activities proposed by the Subcommittees of the Task Force are being 
integrated into the program plans of the agencies represented on the 
Task Force. Moreover, we have had the opportunity to share expertise 
and cultivate working relationships that will last beyond this 
particular effort. As a result, we are better prepared to serve as 
emissaries for positive action within the Department, our communities, 
and professional organizations. 

The Task Force encourages you to identify the appropriate 
mechanisms whereby our recommendations can be incorportated into the 
body of the Department's programs and activities. If these 
recommendations can be implemented with the same spirit as their 
genesis, we will advance as a Department and as a Nation toward 
improving the health status of minority Americans today, with the 
assurance that we will all be healthier Americans tomorrow. 



Sincerely yours. 




Thomas E. Malone, Ph.D. 
Chairman 




THESECHETARV OF HEALTH AND HUMAN SERVICES 

WASHINGTON. D C 20201 



In January 1984 — ten months after becoming Secretary of Health and 
Human Services — I sent Health, United States, 1983 to the Congress. 
It was the annual report card on the health status of the American 
people. 

That report — like its predecessors — documented significant progress: 
Americans were living longer, infant mortality had continued to 
decline — the overall American health picture showed almost uniform 
improvement . 

But, and that "but" signaled a sad and significant fact; there was a 
continuing disparity in the burden of death and illness experienced 
by Blacks and other minority Americans as compared with our nation's 
population as a whole . 

That disparity has existed ever since accurate federal record keeping 
began — more than a generation ago. And although our health charts do 
itemize steady gains in the health status of minority Americans, the 
stubborn disparity remained — an affront both to our ideals and to the 
ongoing genius of American medicine. 

1 felt--passionately — that it was time to decipher the, message inherent 
in that disparity. In order to unravel the complex picture provided by 
our data and experience, I established a Secretarial Task Force whose 
broad assignment was the comprehensive investigation of the health 
problems of Blacks, Native Americans, Hispanics and Asian/Pacific 
Islanders. 

The Task Force under the insightful direction of the distinguished 
Thomas E. Malone, Ph.D. , Deputy Director of the National Institutes 
of Health and with the invaluable contribution of experts from 
throughout the department, has met its challenge. Brilliantly. 
First: by a review of departmental programs to determine how the 
health problems of minorities have been addressed; followed by a 
careful analysis of the range of health care resources and information 
available; and then — by a critique of the health status of Blacks, 
Native Americans, Hispanics and Asian/Pacific Islanders. The Task 
Force was further charged with finding ways for our department to 
exert leadership, influence and initiative to close the existing gap. 
The report is comprehensive. Its analysis is thoughtful. Its thrust 
is masterful. It sets the framework for meeting the challenge — for 
improving the health of minorities. 

It can — it should — mark the beginning of the end of the health disparity 
that has, for so long, cast a shadow on the otherwise splendid American 
track record of ever improving health. 




%^^.ta'9^:4^^^e£^ 



Margaret M. Heckler 
Secretary 



TABLES AND FIGURES 



TABLES 

Table 1. Average Annual Total and Excess Deaths in Blacks, 

Selected Causes of Mortality, 1979-1981 5 

Table 2. Percent Distribution of Persons by Ethnic/Racial 
Background and Sex, Age, and Geographical Area, 
United States, 1980 48 

Table 3. Percent Distribution of Persons of Nonminority 

and Minority Background by Number, Sex, and Geographic 
Distribution, United States, 1980 49 

Table 4. Occupational Distribution of Minority Groups, Ratio of 

Nonminority to Minority 50 

Table 5. Age-adjusted Death Rates by Selected Cause, Race, 

and Sex, United States, 1980 67 

Table 6. Blacks: Average Annual Number of Deaths by Disease 

Category, United States, 1979-1981 71 

Table 7. Hispanics : Average Annual Number of Deaths by Disease 

Category, United States, 1979-1981 77 

Table 8. Native Americans: Average Annual Number of Deaths by 

Disease Category, United States, 1979-1981 80 

Table 9. Relative Risk of Death for American Indians by Cause .... 81 

Table 10. Asian/Pacific Islanders: Average Annual Number of Deaths 

by Disease Category, United States, 1979-1981 82 

Table 11. Proportion of Cancer Deaths Attributed to Different 

Factors 88 

Table 12. Cancer Incidence Rates 

Primary Site and Racial/Ethnic Group 91 

Table 13. Cancer Mortality Rates 

Primary Site and Racial/Ethnic Group 93 

Table 14. Five Year Cancer Survival Rates; 1973-1981 95 

Table 15. Childbearing Patterns among Racial/Ethnic Groups, 

1982 176 



XI 



FIGURES 

Figure 1. Average Annual Age -Ad jus ted Death Rates for All 

Causes, 1979-1981 ' 65 

Figure 2. Life Expectancy at Birth by Race and Sex, United 

States, 1950-1983 66 

Figure 3. Average Annual Excess Deaths for Blacks, 1979-1981 69 

Figure 4. Average Annual Excess Deaths for Black Males, 

1979-1981 72 

Figure 5. Average Annual Excess Deaths for Black Females, 

1979-1981 73 

Figure 6. Average Annual Age-Adjusted Death Rates for Cancer, 

1979-1981 90 

Figure 7. Average Annual Age-Adjusted Death Rates for Heart 

Disease, 1979-1981 108 

Figure 8. Average Annual Age-Adjusted Death Rates for Heart 

Disease, for Persons under 45 Years of Age, 1979-1981 . . . 109 

Figure 9. Average Annual Age-Adjusted Death Rates for Stroke, 

1979-1981 Ill 

Figure 10. Average Annual Age-Adjusted Death Rates for Chronic 

Liver Disease and Cirrhosis, 1979-1981 130 

Figure 11. Percent of People in the Most Obese Group, 1976 151 

Figure 12. Death Rates from Unintentional Injury, Suicide, and 

Homicide by Race, 1977-1979 158 

Figure 13. Average Annual Age-Adjusted Death Rates for Homicide for 

Persons Under 45 Years of Age, 1979-1981 159 

Figure 14. Infant Mortality Rates, 1950-1982 (Blacks and Whites). . . . 172 

Figure 15. Neonatal and Postneonatal Mortality Rates, 1950-1982 .... 173 

Figure 16. Low Birth Rate Ratios According to Race and Ethnicity, 

United States, 1982 175 



Xll 



INTRODUCTION AND OVERVIEW OF THE 
TASK FORCE ON BLACK AND MINORITY HEALTH 



Perspective of the Task Force Study 

Despite the unprecedented explosion in scientific knowledge and 
the phenomenal capacity of medicine to diagnose, treat, and cure 
disease, Blacks, Hispanlcs , Native Americans, and those of 
Asian/Pacific Islander heritage have not benefited fully or equitably 
from the fruits of science or from those systems responsible for 
translating and using health sciences technology. With full 
cognizance of this tragic dilemma in the United States, the Secretary 
of Health and Human Services, Margaret Heckler, established the Task 
Force on Black and Minority Health. , 

Since the turn of the century, the overall health status of all 
Americans has improved greatly. In 1900, the life expectancy for the 
United States population at birth was 47.3 years; for Blacks it was 
much lower--33 years. In little more than three generations, 
remarkable changes have occurred in health care and biomedical 
research. As pointed out by the Surgeon General in the 19 79 report, 
Healthy People , the leading causes of death in 1900 were influenza, 
pneumonia, diphtheria, tuberculosis, and gastrointestinal infections. 
In the first half of the century, improved sanitation, better 
nutrition, and immunizations brought a drastic decline in infectious 
diseases. Today, these diseases cause a relatively small percentage 
of deaths compared to 1900. 

'^ Knowledge about life processes in health and disease is being 
acquired at an incredible pace. Because of one spectacular 
achievement after another, it is predicted that many of the diseases 
not now curable, will.be controlled by the year 2000. This 
i"biological revolution" has placed into the hands of health 
professionals effective medications, new and complex diagnostic 
instruments, and treatment modalities not dreamed of in 1900. 

V Since 1960, the United States population has experienced a steady 
decline in the overall death rate from all causes. Remarkable 
progress in understanding the causes and risks for developing diseases 
such as heart disease and cancer have important implications for the 
health of all Americans. The decline in cardiovascular disease 
mortality from 1968 to 1978 alone improved overall life expectancy by 
1.6 years. Advances in the long-term management of chronic diseases 
mean that conditions such as hypertension and diabetes no longer 
necessarily lead to premature death and disability. 

Concomitantly, advances in social and behavioral sciences 
research and methodology have elucidated relationships among 
biological, behavioral, and social factors that affect health and 
illness. The link among these factors is critical to understanding 



the behavioral underpinnings of health, identifying effective 
strategies for disease prevention, maintaining treatment regimens, and 
suggesting ways to change behavior for more healthful living habits. 



& 



[^Although tremendous strides have been made in improving the 
health and longevity of the American people, statistical trends show a 
persistent, distressing disparity in key health indicators among 
certain subgroups of the populatiorT^ In 1983, life expectancy reached 
a new high of 75.2 years for Whites and 69.6 years for Blacks, a gap 
of 5.6 years. Nevertheless, Blacks today have a life expectancy 
already reached by Whites in the early 1950s, or a lag of about 30 
years. Infant mortality rates have fallen steadily for several 
decades for" both Blacks and Whites. In 1960, Blacks suffered 44.3 
infant deaths for every 1,000 live births, roughly twice the rate for 
Whites, 22.9. Moreover, in 1981, Blacks suffered 20 infant deaths per 
1,000 live births, still twice the White level of 10.5, but similar to 
the White rate of 1960. 



I The Task Force on Black and Minority Health was thus conceived in 
/ response to a national paradox of phenomenal scientific achievement 
/ and steady improvement in overall health status, while at the same 
^time, persistent, significant health inequities exist for minority 
C^Americaris^ As the Task Force came into being in April 1984, it was 
evident that to bring the health of minorities to the level of all 
Americans, efforts of monumental proportions were needed. 

Task Force Activities 

Secretary Heckler appointed Dr. Thomas E. Malone, Deputy Director 
of the National Institutes of Health, the Government's chief agency 
for supporting biomedical research, as Chairperson of the Task Force. 
After careful review of programs and staff of the Department, 18 
senior scientists and officials were selected as primary members of 
the Task Force. These individuals not only had expertise and 
experience in the areas proposed for study, but had the programmatic 
authority affording direct possibilities for implementing 
recommendations of the Task Force. The Task Force members and 
alternates are listed in the appendix to this volume. The Task Force 
was assured the necessary resources to carry out its mandate and was 
supported by a staff that included a wide range of health 
professionals and technical staff from throughout the Department of 
Health and Human Services (DHHS) . 

The Task Force on Black and Minority Health was a unique and 
historic assemblage in its own right. While DHHS has many programs 
that have significant impact on improving the health status of 
minorities, this was the first time that representatives of these 
programs were joined in a common effort to carry out a comprehensive 
and coordinated study to investigate the longstanding disparity in the 
health status of Blacks, Hispanics , Asian/Pacific Islanders, and 
Native Americans compared to the nonminority population. 



The Task Force members developed a broad, multidimensional 
approach to characterizing the health problems of minority Americans. 
The approach was based on analyses of mortality data to define the 
extent of the health disparity, intense examination of the major 
health issues found in the analyses to explore why the disparity 
persists, and consultations with experts in minority health issues from 
the non-Federal community. 

The findings and recommendations generated by the Task Force 
within the confines of a little more than a year's time are summarized 
in this volume. More detailed information supporting the findings 
will appear in subsequent volumes. 

Data Review and Analysis 

In its initial meetings, the Task Force carefully reviewed 
existing health status information for minority and nonminority 
populations available in Health, United States, 1983 and other 
supplementary data sources. After analyzing national mortality data 
for more than 40 disease categories, the approach adopted by the Task 
Force that best defined the disparity was the statistical technique of 
"excess deaths"; that is, the difference between the number of deaths 
observed in minority populations and the number of deaths which would 
have been expected if the minority population had the same age and 
sex-specific death rate as the nonminority population. This method 
quantified the number of deaths that would not have occurred had 
mortality rates for minorities equalled those of nonminorities . 

Because of the paucity of data relating to the health needs and 
mortality of Asian/Pacific Islanders and Hispanics in the United 
States, the Task Force assembled an Asian/Pacific Islander advisory 
group and an Hispanic advisory group. Each group provided the Task 
Force with data and other information on health problems within the 
diverse ethnic groups .that make up the aggregate population and 
initiated special data reviews to supplement inadequate national 
information. 

Native Americans include American Indians, Alaska Natives, and 
Native Hawaiians. -Most statistics cited in this report, however, 
refer specifically. to American Indians and Alaska Natives. Where data 
on Native Hawaiians are available, they are treated separately. 

Identifying the Major Contributors to the Disparity 

In analyzing mortality data from 1979 to 1981, the Task Force 
identified six causes of death that together account for more than 80 
percent of the mortality observed among Blacks and other minority 
groups in excess of that in the White population. Although the 
ranking of health problems according to excess deaths differs for each 
minority population, the six health problems became priority issue 
areas for Task Force study. Listed in alphabetical order, they are: 



• Cancer 

• Cardiovascular disease and stroke 

• Chemical dependency, measured by deaths due to cirrhosis 

• Diabetes 

• Homicide and accidents (unintentional injuries) 

• Infant mortality 

Table 1 presents the leading causes of excess mortality and the 
percentage that each cause contributed to the total excess deaths in 
Blacks for the years 1979 to 1981. For Black males and females 
combined, excess deaths accounted for 47 percent of the total annual 
deaths in those 45 years old or less, and for 42 percent of deaths in 
those aged 70 years or less. More detailed analyses of excess mortality 
appear in the section "Mortality and Morbidity Indicators." 

In addition to measures of excess deaths, special analyses of 
morbidity and health status indicators for minorities were developed 
by the Task Force. These indices included prevalence rates of 
selected chronic and infectious diseases, hospital admissions, 
physician visits, limitation of activity, and self -assessed health 
status. Prevalence of arthritis, digestive diseases, dental problems, 
and respiratory disease among minorities is poorly documented and data 
were virtually unavailable. Additional mortality indices included 
person-years of life lost, life expectancy, and relative risk of death 
by cause. A summary of these findings is included in the section 
entitled "Mortality and Morbidity Indicators." 

Some factors contributing to minority health status are not 
disease-specific but have bearing on the overall health needs of each 
minority group. Among those that the Task Force reviewed are 
demographic data characterizing the four minority groups, minority 
needs in health education, health professionals, and health care 
services and financing. A summary of issues that cut across health 
problem areas appears in the sections of this report entitled 
"Social Characteristics of Minority Populations" and "Health 
Services and Resources for Minorities. 

Subcommittee Activity 

For each of the six causes of death identified as a priority 
area, a Subcommittee was formed to explore why and to what extent the 
disparity exists and what DHHS can do to reduce it. The Subcommittees 
were charged with investigating the physiological, cultural, and 
societal factors that, in combination, perpetuate health inequities 
for minorities. They sought to understand the etiology of selected 
conditions for different minority groups, explore potential means for 
improving the effectiveness of treatment, and identify possible 
intervention strategies to prevent excess death and injury in minority 
groups. Because of the differences among minority groups, the 
Subcommittees addressed each issue with special attention to the 
cultural milieu of that population group. 



Tkble 1 



Average Annual Total and Excess Deaths in Blacks 
Selected Causes of Mortality, 
United States, 1979-1981 





Excess Deaths 
Males and Females 
Cumulative to Age 45 


Excess Deaths 
Males and Females 
Cumulative to Age 70 




Number 


Percent 


Number 


Percent 


Causes of Excess Death 










Heart Disease and Stroke 


3,312 


14.4 


18,181 


30.8 


Homicide and Accidents 


8,041 


35.1 


10,909 


18.5 


Cancer 


874 


3.8 


8,118 


13.8 


Infant Mortality 


6,178 


26.9 


6,178 


10.5 


Cirrhosis 


1,121 


4.9 


2,154 


3.7 


Diabetes 


223 


1.0 


1,850 


3.1 


Subtotal 


19,749 


86.1 


47,390 


80.4 


All Other Causes 


3,187 


13.9 


11,552 


19.6 


Total Excess Deaths 


22,936 


100.0 


58,942 


100.0 


Total Deaths, All Causes 


48,323 




138,635 




Ratio of Excess Deaths to Total Deaths 


47.4% 




42.5% 




Percent Contribution of 
Six Causes to Excess Death 


86.1% 




80.4% 





The Subcommittees reviewed existing data and literature and 
consulted with experts and organizations within and outside the 
Federal government. When scientific information for a particular 
issue was not readily available, research papers were commissioned to 
review recent data in each Subcommittee's area. Material from most of 
the commissioned papers was incorporated into the Subcommittee 
reports. Many of the authors contributed new analyses that augmented 
national information already available to the Task Force. 

Interaction With the Non- Federal Community 

In order to supplement its knowledge of minority health issues, 
the Task Force had extensive interaction with individuals and 
organizations outside the Federal system. 

Presentations . The Task Force and its Subcommittees heard 
presentations by experts in several issue areas . Presentations 
included public health aspects of homicide and homicide prevention; 
special problems concerning the health status of Asian/Pacific 
Islanders, and American Indians and Alaska Natives; the political 
history, demography, and health-related conditions of Hispanics ; 
and the use of traditional folk medicine and healers by various 
minority groups . 

Outreach . Task Force members and staff attended national meetings 
of non-Federal professional organizations to inform their 
membership of the work of the Task Force and to solicit their views 
on health priorities and model intervention programs. 

Non-Federal community survey . The Task Force surveyed more than 
350 non-Federal organizations and individuals concerned with 
minority health issues. The survey requested opinions about 
critical factors affecting the health status of minorities, and 
requested examples of successful programs and suggestions for ways 
that DHHS might better address minority health needs. This survey 
may help to initiate cooperative efforts between the Federal and 
private sectors for improving minority health. A summary of the 
survey results appears in the section of this report entitled 
"Survey of Non-Federal Organizations." 

Program Inventory 

The Task Force conducted an inventory of health care, research, 
and prevention programs sponsored by DHHS that specifically affect 
minority populations. The inventory of DHHS programs and projects is 
the first such compilation describing existing programs oriented 
toward minority health in DHHS . An index to the inventory is found in 
the section "inventory of DHHS Program Efforts in Minority Health. 



Task Force Report 

The first volume of the Task Force Report summarizes the 
information and data compiled on specific minority health problems, 
special reports developed on cross-cutting minority health issues, and 
recommendations proposing activities for a coordinated effort by which 
DHHS may redirect its resources to address the demonstrated disparity 
in health status between minority and nonrainority populations. For 
greater understanding of the urgency and complexity of the issues 
around which the recommendations were developed, all sections of the 
report should be examined. 

Subsequent volumes of the report contain the complete text 
prepared by the Subcommittees that support their findings and proposed 
intervention strategies. They are excellent reviews of research and 
should be regarded as state-of-the-art information on specific problem 
areas in minority health. Subsequent volumes also contain the 
complete inventory of DHHS programs and projects that benefit 
minorities, and an annotated bibliography listing selected topics 
related to Hispanic health issues. 

The report of the Task Force looks to the future. It 
concentrates on specialized activities that should have a direct and 
timely impact on the problems of minority health. Apart from the 
descriptions of DHHS programs referenced in the program inventory, the 
report does not analyze or examine the many departmental activities 
and services that benefit all Americans, including minorities, such as 
the extraordinary advances in biotechnology and molecular biology. 

In compiling its data, the Task Force tapped a broad range of 
sources. Much information is based on the data systems of the 
National Center for Health Statistics. Some data resulted from 
special analyses conducted for the Task Force or studies from other 
sources. Data comparisons are generally made between minority and 
nonminority groups except in those situations where study data 
specified White populations or aggregate (all races) populations. 
Because the report was assembled during a year's time, more recent 
data on some topics may now be available. 

Context for the Task Force Recommendations 

The Task Force acknowledged that the factors responsible for the 
health disparity are complex and defy simplistic solutions. Health 
status is influenced by the interaction of physiological, cultural, 
psychological, and societal factors that are poorly understood for the 
general population and even less so for minorities. 

Even though the shared characteristic of economic disadvantage among 
minorities suggests the possibilities of common approaches for 
achieving improved health, diversity within and among minorities 
necessitates activities, programs, and data collection tailored to 



meet their health needs. The Task Force further observed that since 
minorities are underrepresented as beneficiaries of the predominantly 
nonminority health care establishment, efforts by all sectors must 
proceed vigorously in areas in which current knowledge can suggest 
action. 

Recommendations were developed to emphasize the following 
principles: incorporate minority health initiatives into existing 
DHHS program areas in order to address health conditions amenable to 
immediate improvement, press for greater public and private 
involvement in a common effort to eliminate the health disparity, 
resolve unanswered questions through a concerted program of research 
and data collection, and seek new strategies to ameliorate health 
inequities between minorities and nonminorities . 

In the context of these general observations and with information 
obtained from a broad range of experts in the field and its own 
deliberations, the Task Force began the long and arduous 
recommendation development process. 

Early in the process, the Task Force recognized that many 
activities of major importance to minority groups were already in 
progress within DHHS. Therefore, the Task Force decided to emphasize 
new directions for departmental activities in its efforts to reduce 
the minority health disparity. Many of these activities are indicated 
within the recommendations that follow. The Subcommittees, however, 
proposed many other opportunities that relate more specifically to the 
health priority areas. They appear in the Subcommittee reports as 
"Opportunities for Progress." The reader is urged to consider them as 
extensions of the recommendations. 

The recommendations are organized into six categories. They 
emphasize areas in which the Task Force members believe further 
improvements were urgently needed. The categories are: 



• Health information and education 

• Delivering and financing health services 

• Health professions' development 

• Cooperative efforts with the non-Federal sector 

• Data development 

• Research agenda 

The Task Force joins with all concerned citizens in acknowledging 
the stark reality of the continuing, significant differences between 
the health of racial/ethnic minorities in the United States and the 
general population and proposes recommendations for DHHS and others in 
the public health community to address these problems. 



Recommendations 
of the Task Force 




HEALTH INFORMATION AND EDUCATION 

Introduction 

The ability to make informed decisions plays a significant role 
in influencing the overall health status of Americans. Though not a 
panacea, health education has been effective in increasing public 
awareness about actions individuals and communities can take to 
enhance personal health. The disparity in the death rate between 
nonminority and minority populations in the United States (Blacks, 
Hispanics, Asian/Pacific Islanders, and Native Americans) is a 
compelling reason to investigate how health education can contribute 
toward reducing this disparity. Because many of the identified 
behavioral and environmental risk factors associated with the causes 
of excess deaths among minorities can be controlled, more work is 
needed to educate minority populations about the risk factors for the 
six areas identified as having the greatest impact on minority health: 
cancer; cardiovascular disease; chemical dependency; diabetes; 
homicide, suicide, and unintentional injuries; and infant 
mortality. 

RECOMMENDATION 1: AN OUTREACH CAMPAIGN 

The Department should launch an outreach campaign to disseminate 
health information and education materials and program strategies 
specifically designed for minority sectors of the population, 
including Blacks, Hispanics , Asian/Pacific Islanders, and Native 
Americans. The campaign should strengthen and expand present 
departmental health promotion efforts emphasizing preventive aspects 
of those public health areas identified by the Task Force which have 
the greatest impact on death and disability among minority 
populations : cancer; cardiovascular disease; chemical dependency; 
diabetes; homicide, suicide, and unintentional injuries; and infant 
mortality. 

Access to Health Information 

The Task Force has reviewed data suggesting that minority 
populations may be less knowledgeable or aware about some specific 
health problem areas than nonminorities . This situation is 
particularly critical in those areas where minorities suffer a greater 
burden of illness than nonminorities. For example. Blacks and 
Hispanics have less information about cancer and heart disease than do 
nonminority groups : 

• Blacks tend to underestimate the prevalence of cancer, give 
less credence to the warning signs, get fewer screening tests, 
and are diagnosed at later stages of cancer than nonminorities. 



• Hispanic women have less information about breast cancer than 
do nonminority women. Hispanic women were less aware that 
family history is a risk factor for breast cancer, and only 
25 percent of Hispanic women have heard of breast 
self-examination. 

• Many professionals and lay persons, both minority and 
nonminority, do not know that heart disease may be as common in 
Black men as in nonminority men or that Black women die from 
coronary disease at a higher rate than nonminority women. 
Hypertensive Japanese women and younger men (18 to 49) are 
less aware of their hypertension than are the nonminority 
subgroups, according to a 1979 survey. Among Mexican Americans, 
cultural attitudes regarding obesity and diet are often 
barriers to achieving weight control. 

Programs to increase public awareness about health problems have 
been well received in several areas. For example, the Healthy 
Mothers/Healthy Babies Coalition, which provides an education program 
in both English and Spanish, has contributed to increased awareness of 
measures to improve health status of mothers and infants. Also, 
increased knowledge among Blacks of hypertension as a serious health 
threat is one of the accomplishments of the National High Blood 
Pressure Education Program. The success of these efforts indicates 
that carefully planned programs have a beneficial health effect; but 
the job is not complete and efforts must continue. 

Planning Health Information 

Sensitivity to cultural factors is often lacking in health care 
of minorities. Although DHHS has considered cultural orientation in 
many of its health information programs, improvement is needed. 
Experience has shown that\ key concepts to consider in designing a i| J ,\-j 
health information campaigrnhclude: meeting the language and ir\W* 
cultural needs of each identified minority group, using \j) 

minority-specific community resources for tailoring educational 
approaches, and developing materials and methods of presentation 
commensurate with the educational level of the target populatioir?> 
Furthermore, because of the powerful influences of cultural factors 
over a lifetime in shaping people's attitudes toward health behaviors, 
health information programs must be sustained over a long period of 
time. Examples of how these concepts might be interwoven into health 
promotion efforts follow. 

• Channel efforts for Black, Hispanic, Asian/Pacific Islander, 
and Native American communities through local leaders, who 
could represent a powerful force for promoting acceptance and 
reinforcment of the central themes of health promotion messages, 



10 



• Data suggest that health messages are more readily accepted if 
they do not conflict with existing cultural beliefs. Where 
appropriate, messages should acknowledge existing cultural 
beliefs . 

• Involve family, churches, employers, and community organizations 
as a support system to facilitate and sustain behavior change 

to a more healthful lifestyle. For example, although 
hypertension control in Blacks depends on appropriate medical 
therapy, blood pressure control can be improved and maintained 
by family and community support of activities such as proper 
diet and exercise. 

• Language barriers, cultural differences, and lack of adequate 
information on access to care complicate prenatal care for 
Hispanic and Asian women who have recently arrived in this 
country. A model program in Hartford, Connecticut, uses volunteer 
minority lay health workers to organize community support networks 
to promote perinatal care by disseminating culturally appropriate 
health information to Hispanic women. 

• Homicide is the leading cause of death for young Black men and 
one of the leading causes of death for Hispanic men and Black 
women. It is a major contributor to the disparity in mortality 
rates between these groups and nonminorities . Homicide 
prevention activities should include strategies such as 
behavioral modification interventions for handling anger and 
community-based programs that call attention to the extent and 
consequences of violence in Black and Hispanic communities. 

• Task Force data suggest that the health of some young Hispanic 
and Native Americans may be seriously threatened by the emerging 
use of inhalants. Communities where young people are at risk 
because of increasing use of such substances would benefit 

from an appropriate and culturally sensitive health education 
campaign to address this problem at the community level. 

DEPARTMENTAL ACTIVITIES 

In carrying out an outreach campaign to meet the health information 
needs of minority populations, DHHS should initiate the following 
activities : 

• Assess existing departmental materials to ascertain whether 
health information materials available to minority populations 
are sensitive to their culture and appropriate to their language 
and reading level. Reorient existing health information 
materials as necessary. 



11 



7 



'/ 



• Review the accessibility of health information and educational 
materials available to identified minority populations. 

• Develop new health information and educational materials, suitable 
for specific minority groups, where none already exist. New 
materials should be formulated to be acceptable to the cultural 
and language needs of each targeted population. 

• Develop media-based messages in different languages at 
appropriate reading levels, including culturally relevant verbal 
and print messages, to increase awareness and provide knowledge 
of health issues, and promote behavior change to a more healthful 
lifestyle. 

• Test improved or new materials before general distribution to 
determine if the materials are both culturally acceptable and 
useful to the target audience. 

• Enlist the participation and counsel of professional and lay 
members of each minority group to assess the suitability of 
existing departmental health information materials, reorient 
materials to specific minority groups, develop new materials, 
and distribute the materials through the appropriate 
minority-specific networks. 

• Encourage private organizations such as religious and community 
organizations, clubs, and schools, to participate in developing 
minority support networks and other incentive techniques to 
facilitate the acceptance of health information and education. 

• Emphasize information and educational materials in those areas 
where the health problems are identified as most severe, the 
target population is at highest risk, and interventions are 
likely to result in improved health status. 

• Distribute health information through the established 
communication networks, public and private, within minority 
communities . 

• Evaluate the impact of these efforts on health-related behavior 
and, where appropriate, on morbidity and mortality. 

Patient Education 

The benefits of health education for overall health promotion 
require a relatively long period of time to be realized. Patient 
education is a component of health education that requires a much 
shorter time for its benefits to be observed. Patient education 
includes increasing a person's knowledge about identified health 
problems and strengthening the ability to care for that condition. 



12 



Knowledge of appropriate self -care, treatment regimens, or beneficial 
behavioral changes can influence an individual's health status 
significantly and alter the probability of adverse health outcomes. 

RECOMMENDATION 2: PATIENT EDUCATION 

The Department should ensure that its materials , programs , and 
technical assistance for patient education are responsive to minority 
population needs, especially those provided in specific health care 
service settings such as medical, community-based , school and 
worksite locations . Emphasis should be given to those public health 
topics that have the greatest impact on death and disability in 
minority populations . Concomitantly , attention should be given by the 
Nation' s schools and universities to training health care providers 
and educators to be sensitive to minority cultural and language 
needs . 

Patient Education Is Interpersonal 

Patient education is often linked to the delivery of medical care 
or a specific health problem and frequently takes place in special 
settings, such as hospitals, schools, communities, homes, or the 
worksite. Although printed materials and information contribute to 
the educational process, patient education is inherently 
interpersonal. The success of the educational effort is often 
determined by the credibility of the source of patient education and 
is highly dependent on the skill and sensitivity of the health care 
provider. 

Task Force data suggest that physicians, often seen in clinics or 
emergency rooms, are the primary source of health information for 
Black and Mexican American patients. In addition, Mexican Americans 
regularly seek advice from family members on health matters. American 
Indians and Alaska Natives living on reservations rely on Public 
Health Service health practitioners or community health 
representatives for information. Some Asian/Pacific Islanders may 
use traditional healers in combination with physicians. These 
differences among the minority groups need to be given due recognition 
in the design and delivery of patient education services. 

Patient education programs are particularly critical and needed 
for several health problems where the impact on minority health is 
greatest, such as hypertension, obesity, and diabetes. 

Patient Education Is Cost Effective 

Task Force data suggest that patient education is effective in 
reducing the cost of health care. For diabetics, it has been estimated 
that improving self-management skills through education could reduce 
the complications of diabetes--ketoacidosis , blindness, and amputations- 
by up to 70 percent, preventing about 50,000 hospitalizations a year. 



13 



Costs for prenatal education of pregnant women fall far short of the 
estimated $15,000 required for medical services for each low birth 
weight infant. 

Hospitals in Memphis and Atlanta have had projects lasting more 
than a decade that offered prevention-oriented education programs 
geared to early detection, therapy, and continuing follow-up care for 
diabetics, on the assumption that prevention is effective both in 
therapeutic effects and in cost. The results have supported this 
assumption. The Atlanta program has saved an estimated $11 million in 
costs, and the Memphis program, similarly cost effective, has seen 
reductions in hospitalizations and diabetic complications. Given the 
high prevalence of diabetes among Blacks, Hispanics , American Indians, 
and some Asians, the potential for further savings in dollars and 
suffering is considerable. 

DEPARTMENTAL ACTIVITIES 

Departmental activities to ensure that patient education materials 
and programs are available and suitable to specific minority groups 
should include the following recommendations: 

• Review and assess existing patient education materials, messages, 
and media in the Department to determine their applicability 

and suitability to specific minority groups. Minority group 
representatives should participate in planning and evaluating 
the appropriateness of materials, messages, and media 
addressing the major health problems confronting the 
minorities . 

• Develop new patient education materials, messages, and media as 
needed, tailored to the specific needs of minority populations 
and designed for use in specific health care settings. 

• Encourage health professions' training institutions to develop 
training programs so that health care providers such as 
physicians, dentists, nurses, social workers, health educators, 
lay counselors, allied health professionals, and volunteers may 
gain increased awareness of and sensitivity to the health problems 
and health attitudes, beliefs, and concerns of minority 
populations . 

• Ensure that minority-specific patient education programs 
incorporate culturally relevant reasons why patients should 
comply with the necessary medical regimen. Mechanisms for 
involving minority organizations and disease-specific voluntary 
organizations should be explored. 



14 



DELIVERING AND FINANCING HEALTH SERVICES 

Introduction 

The Task Force has reviewed data that indicate low income and 
lack of health insurance coverage are among the most serious barriers 
to seeking health care. Minorities are disproportionately represented 
among impoverished Americans. The Department can serve as a catalyst 
to promote action by private and public entities to address these 
problem areas more effectively. 

RECOMMENDATION 3: DELIVERY AND FINANCING OF HEALTH SERVICES 

The Department should continue to investigate , develop, and 
implement innovative models for delivery and financing of health 
services , based on current departmental authorizations . The major 
objectives of the models should be to increase flexibility of health 
care delivery , facilitate access to services by minority populations , 
improve efficiency of service and payment systems, and modify services 
to be more culturally acceptable . 

Traditional Measures of Health Care Services 

The most commonly used indicators of the adequacy of health 
services for a population include distribution of physicians, 
percentage of a specified population who did not see a physician 
during the past year, and average number of visits to a physician. 
For these gross indicators, data are lacking for some minority groups. 

These data do suggest that, in general, availability of health 
care professionals and utilization of health services for all 
Americans have increased: 

• The rate of increase in the number of physicians in the United 
States has more than kept pace with the growth of the American 
population. During the period from 1970 to 1982, the American 
population grew by 11 percent, while the number of physicians 
grew by 51 percent. With the exception of Native Americans, 
most minority populations live in geographic areas where 
physicians are present. Little is known, however, about the 
practice patterns of medical specialists and the extent to 
which they treat minorities. 

• In 1970, the percentage of people who had not seen a 
physician in the past 12 months was 30 percent for Whites and 
42 percent for non-Whites (■'•) . During the period from 1978 to 



The Census definitions of White and non-White were used in 1970. 
People of Mexican or Spanish descent were coded "White," and Native 
Americans, Asian/Pacific Islanders, and Blacks were coded "non-White." 



15 



1980, these percentages were 23 percent for Whites, 24 percent 
for Blacks, 33 percent for Mexican Americans, and 20 to 24 
percent for other Hispanic groups . 

• In 1970, the average annual number of visits to a physician per 
year was 4.1 for Whites and 3.6 for non-Whites. During the 
period from 1978 to 1980, the average number of physician visits 
rose to 4.8 for Whites, 4.8 for Blacks, 4.3 for Mexican 
Americans, and from 5.1 to 6.1 for other Hispanic groups. 

No absolute standards are available for measuring adequacy of 
health services. Data for nonminorities, however, provide a base 
against which to compare the use of health services by minorities . In 
sum, gross indicators of access to and utilization of health services 
show improvement for the Nation as a whole and for those minorities 
for whom data are available. 

Traditional Measures Are Incomplete 

The narrowing of the disparity in reported use of health services 
between minorities and nonminorities is an encouraging trend. The 
data, however, are lacking for many of the minorities. Moreover, the 
indicators themselves do not reflect delays between the onset of 
problems and the seeking of medical attention, severity of the problem 
when care is sought, quality of the care received, and whether 
appropriate referrals are made to specialists. 

Information provided to the Task Force from a variety of 
non-Federal sources, including health professional and minority 
organizations, and the Tasks Force's professional judgment indicate 
problems relating to health services persist for minorities. The 
following exemplify such problems: 

• The disparities in death rates between minorities and 
nonminorities remain despite overall increases in access and 
utilization that have been noted. 

• Language problems hamper refugees and immigrants when 

they seek medical care and try to explain their symptoms to 
providers . 

• Blacks with cancer tend to postpone seeking diagnosis 
of their symptoms longer than do nonminorities, and 
delay initiation of treatment once diagnosed. 



• 



A smaller proportion of Black women than White women begin 
prenatal care in the first trimester of pregnancy (63 percent 
versus 76 percent in 1980) , a factor related to the high Black 
infant mortality rate. The 1990 health objective for prenatal 
care states that a minimum of 90 percent of mothers in any racial 
or ethnic group should begin care in the first trimester of 
pregnancy. 



16 



• The postneonatal death rate, which constitutes the bulk 

of infant mortality for American Indians and Alaska Natives, 
remains high. Postneonatal mortality implies an adverse milieu 
for the infant and is thought to result from such problems as 
infectious diseases, unintentional injuries, and a lower use of 
health care for these acute problems. 

Continuity of Care 

Continuity of care is associated with improved health outcomes 
and is presumably greater when a patient is able to establish an 
ongoing relationship with a particular provider. The issue is central 
because many of the major killers of minorities, such as cancer, 
cardiovascular disease, and diabetes, are chronic rather than acute 
problems and require repeated visits and extended treatment 
regimens . 

• A higher percentage of Blacks and Hispanics than Whites 
report that they they have no usual source of medical care (20 
and 19 percent versus 13 percent) . 

• Proportionately fewer Blacks and Hispanics than Whites report 
that they use a physician's office as their usual source of care 
(46 and 54 percent versus 70 percent) . 

• Proportionately twice as many Blacks and Hispanics than 
Whites report they use hospitals and health clinics as their 
usual source of medical care. In 1980, more than 25 percent of 
all visits to physicians made by Blacks occurred in hospital 
clinics or emergency rooms compared to 11 percent by Whites. 

• Refugees are eligible for special refugee medical assistance 
during their first 18 months in this country. After this, 
however, refugees who cannot afford private health insurance and 
who are ineligible for Medicaid or state medical assistance may 
become medically indigent. 

• Many American Indians and Alaska Natives live in areas where 
the availability of physicians is half the national average, 
and the Indian Health Service may not be able to provide 
coverage. 

Financing Problems 

Many of the minorities tend to rely on Medicaid and charity care 
for their medical treatment because they have no other sources of care 
or ways to finance that care. Elderly minority people are less likely 
than Whites to supplement Medicare with additional private 
insurance. 



17 



• Proportionately three times as many Native Americans, Blacks, 
Hispanics, and certain Asian/Pacific Islander groups as 
nonminorities are impoverished (29 percent to 35 percent versus 
11 percent) . 

• Proportionately twice as many Blacks and three times as many 
Hispanics as nonminorities have no medical insurance whatsoever 
(18 percent and 26 percent versus 9 percent). 

• Of those who had no insurance, 35 percent did not see a physician 
during the past 12 months compared to 22 percent for those who did 
have insurance. 

The problem of how to apportion fairly the costs associated with 
uncompensated hospital care is a major concern. The traditional 
practice of paying for this care through increased charges to other 
individuals and third party payers has become increasingly 
unacceptable as price competition among hospitals has heightened. 

Public and private, not-for-profit, inner city hospitals bear the 
greatest share of the uncompensated care burden and are not likely to 
offset these expenses by attracting more paying patients. Unless 
solutions to the uncompensated care problem are found, the financial 
viability of these institutions may be in doubt. Access to health 
care is predicated upon the ability of both individual providers and 
institutions to meet the needs of the populations they serve. 

Many States are now exploring the issue of uncompensated care 
through task forces or commissioned studies. 

The composition of each State s medically indigent population 
varies according to its employment patterns, degree of unionization, 
structure of its Medicaid program, and other factors which differ 
among States. It is important, therefore, to encourage the States to 
undertake their own data collection efforts to define their medically 
indigent populations and devise policy initiatives that meet their 
particular needs. The DHHS can provide a clearinghouse function in 
these endeavors by providing baseline information, making available 
the results of other States' inquiries and initiatives, and providing 
technical assistance on questions of methodology. 

Implications of Diversity 

America is rich in the diversity of its minorities. There are 
more than 500 federally recognized American Indian tribes, 23 
different countries of origin for Asian/Pacific Islanders, and three 
major places of origin for Hispanics. This diversity among 
populations is reflected in language difficulties, in cultural 
practices and beliefs with respect to illness and health, in 



18 



differences in their birth rates, in differences in the afflictions 
which kill them, and in differences in their needs for types of 
services and the duration of health care. 

DEPARTMENTAL ACTIVITIES 

The following activities should be pursued by the Department in 
the area of delivering and financing health services. 

• Serve as a resource to States as they study the problem of 
health care for the medically indigent. Encourage States to 
include consideration of minority subgroups in their research. 
Place a particular focus on the employed uninsured. 

• Evaluate the changes taking place in the health care 
environment to assess their effect on uncompensated care and, 
in particular, on public hospitals. Resulting actions could 
lead, for example, to the formation of risk or revenue pools by 
the States . 

• Emphasize prevention and primary care and promote, through 
existing program authorities, the concept of community-oriented 
primary care in those areas where problems of access appear to 
predominate. 

• Target Federal categorical initiatives to trouble spots 
identified through the mid-course review of progress toward the 
1990 Health Promotion/Disease Prevention objectives. 

• Continue and expand the Department's participation in the 
Healthy Mothers/Healthy Babies Coalition, which has proven 
successful in addressing the issue of prenatal and perinatal 
care for low income women. 

• Expand prenatal care Medicaid benefits, within existing 
program authorities, for high-risk pregnant women to include: 
nutrition supplements, psychosocial and health education classes, 
birth education classes, prenatal vitamins, and other health care 
upon authorization by the woman's physician. 

• Use the established communication networks of organizations 
within minority communities as conduits for the dissemination 
of information about health promotion, disease prevention, and 
the use of health services. 



19 



HEALTH PROFESSIONS DEVELOPMENT 

Introduction 

Health care professionals are essential to any program that aims 
to improve the health status of minorities, since they are the 
providers who assist in preventing illness and restoring health. The 
Task Force recognizes this centrality and believes the Department must 
forge a partnership with the health professions' community and others 
to address jointly the health issues confronting minorities. The Task 
Force presents recommendations for developing health professionals 
both outside and within the Federal Government. 

RECOMMENDATION 4: DEVELOPING STRATEGIES OUTSIDE THE 

FEDERAL SECTOR 

The Department should initiate discussions with minority and 
nonminority health professional organizations , academic institutions. 
State governments and health departments , and other entities from the 
public and private sectors , to develop strategies to improve the 
availability and accessibility of health professionals to minority 
communities . 

Considerations for Discussion 

Analyses of data on the availability of health professionals have 
provided some insight into the issue of the persistent disparity in 
the health status of minorities. Several factors, however, require 
further investigation concerning minority and nonminority health 
professionals and their roles in minority communities. 

• Minorities (and nonminorities) live in communities that do 
not generally conform to the specific geographic boundaries 

of political jurisdictions (states, counties, wards, districts, 
etc.). Minority communities are not evenly distributed and 
frequently cross over these geographic boundaries. In contrast, 
record-keeping and other processes for monitoring (and 
potentially influencing) the availability of health professionals 
and resources are generally determined by and restricted to these 
political boundaries. 

• The size of a minority group, number of cultural subgroups, 
and demographic features such as pattern and distribution of 
minority communities are factors that influence the number of 
health professions' students that each group might be expected 
to generate and the degree to which a minority group can 
support a cadre of health professionals in their communities. 
With few exceptions, minorities are underrepresented as 
students and practitioners of the health professions. For 



21 



example, the percentage of Blacks (11.5 percent of the population) 
in medical schools has decreased from a high of 6.3 percent 
(1974-75) to 5.5 percent (1983-84). 

• Differences in the availability of health personnel resources 
to minority communities are apparent regardless of the minority 
group being considered. Communities located in urban/metropolitan 
counties appear to have significantly more professional resources 
available. Some of these professionals, however, are committed as 
faculty, administrators, and researchers, thus making their 
patient care contributions difficult to evaluate. The 
aggregate number of health professionals in cities overstate 

the actual availability of practitioners for patient care. 

• The availability and accessibility of health personnel are 
separate but related issues. The first is a critical initial 
measure of resource potential, but is not an effective measure 
of health care capability unless the latter is also considered. 
Both of these critical issues must be addressed in planning for 
the future. 

In addition to these considerations, increasing health personnel 
resources must involve interaction among the several groups that 
influence the health professions. Most of the health disciplines 
which collect data on their professional members do so on a national 
basis. Licensure of practitioners is accomplished at the State level, 
while accreditation of training institutions and certification of many 
allied health professionals is done by national and State bodies. 
Interests should be discussed and coordinated between those who 
influence the numbers and types of health personnel and those who 
wish to increase the numbers of health professionals in specific 
geographic areas . 

Data on the participation of each minority group and subgroup in 
the various health professions is a prerequisite to determining how 
these personnel contribute to improving the health status of minority 
communities. Data on students are more readily available than 
data on practitioners, but even these are not available for many 
health disciplines and/or for many minority subgroups. 

DEPARTMENTAL ACTIVITIES 

The following activities recommended for DHHS would provide a 
mechanism for sharing the Task Force's findings with the health 
professions community, and concurrently provide a forum for dialogue 
between interested and involved parties at all levels. Discussions 
with the non-Federal sector should: 

• Provide for a better integrated system for the collection 
and analysis of data on: the numbers of health 
professionals providing health care within minority 
communities; the practice patterns and demographic features of 



providers who serve these communities; and the numbers of 
minority health professional students in training by- 
discipline. 

• Identify implementation strategies to address critical health 
professions' educational issues, such as: increasing minority 
participation in the various training areas; strengthening 
training program curricula by making them more culturally 
sensitive to minority patients and minority health problems as 
identified in this report; and providing continuing education 
programs for training on minority health issues. 

Activities Witiiin the Federal Government 

Development of a partnership for action with health professionals 
outside the Federal Government should be supplemented with coordinated 
action within the Federal Government. The Federal Government 
maintains a substantial health professions' resource within the 
Department and other elements of the Executive Branch. This resource 
can and should be provided with the findings of this report so that a 
cohesive approach may be developed with respect to the availability 
and accessibility of health professionals to minority communities. 

RECOMMENDATION 5: DEVELOPING STRATEGIES WITHIN THE 

FEDERAL SECTOR 

The Department should conduct both intra- and interdepartmental 
reviews to identify and provide for collaboration between the various 
activities currently being supported within the Department and other 
elements of the Executive Branch, respectively . The reviews should 
focus on programs that have impact on the actual or potential 
availability of health professionals to minority communities. 

Coordinated Effort 

The Federal Government maintains a substantial health professions 
resource. For example, it employs more than 18,000 physicians engaged 
in a variety of activities which affect the health care of the Nation. 
Within DHHS , the Public Health Service supports a number of programs 
designed to address shortages of minority health professionals (as 
practitioners and researchers) and place health professionals in 
medically underserved areas. These resources should not duplicate 
actions taken by other entities within DHHS or by other Federal 
agencies . 



23 



DEPARTMENTAL ACTIVITIES 

As part of the proposed reviews, discussions and dialogue between 
responsible program officials should be stimulated to enhance DHHS 
ability to address the persistent problems of providing health 
professionals for underserved minority communities. Examples of 
activities which DHHS could undertake follow: 

• Sponsor a series of conferences, directed toward practitioners, 
to promote the findings of this report and to develop health 
education and health promotion techniques for minority 
populations. The seminars should be made available to those 
practitioners within the National Health Service Corps, the 
Indian Health Service, and practitioners working under 
DHHS grants, to identify areas where the impact of their 
respective resources on minority communities might be 
enhanced. 



• Encourage other Departments and agencies of the Executive Branch, 
especially the Veterans' Administration, to conduct training seminars 
on health education and health promotion techniques for minority 
populations. The seminars should foster interdepartmental support 

to improve the health of minorities. 

• Collaborate with other agencies in the Executive Branch, such 
as the Department of Education, the National Science 
Foundation, and others, to encourage more minority researchers 
to apply for Federal research grants, and to encourage more 
minority science faculty appointments to health and 
health-related training institutions. A model program that 
addresses the problem is the National Cancer Institute's 
Minority Investigator Supplement to Investigator Initiated 
Awards, which provides a means for entering into research grant 
programs and the opportunity to utilize the research skills of 
the minority investigator. 

• Examine ways to increase minority representation in 
preventive medicine, public health, health education, 
communications, and other health professions. 



24 



COOPERATIVE EFFORTS WITH THE NON-FEDERAL SECTOR 



Introduction 

Activities to improve minority health cannot be confined solely 
to the Federal Government. The participation of organizations at all 
levels --National, State, municipal, and community-is vital to achieve 
improved health for minority individuals. State and municipal 
agencies are increasingly aware of the unique needs of their minority 
residents. Many localities, in fact, have developed plans to meet the 
national 1990 objectives for their health care needs. 

The private sector can often be a very effective channel for 
programs targeted to minorities. National organizations concerned 
with minorities such as the National Urban League and the Coalition of 
Hispanic Mental Health and Human Services Organizations (COSSMHO) 
include health-related issues in their national agendas and are 
actively seeking effective ways to improve the health of minorities. 
Organizations such as these have a powerful potential for effecting 
change among their constituencies because they have strong 
community- level , "grass roots" support. 

Changes in health behavior frequently depend on personal 
initiative and are most likely to be triggered by health promotion 
efforts originating from locally-based sources. Indeed, community 
involvement in developing health promotion activities can contribute 
to their success by giving credibility and visibility to the 
activities, and by facilitating their acceptance. By addressing 
health problems that occur within their own communities, minority 
residents can empower themselves to press more actively for adequate 
and comprehensive efforts aimed at improving the health of individuals 
and the community. 

Not all minority communities, however, have the ability to 
identify their own health problems and initiate activities to address 
them. It is here that the Federal Government's knowledge and 
expertise in health can join with community and other non-Federal 
groups to strengthen minority-related health activities. 

RECOMMENDATION G: BUILD THE CAPACITY OF THE NON-FEDERAL 

SECTOR TO ADDRESS MINORITY HEALTH 
PROBLEMS 

DHHS should increase its involvement with State, local, and 
community agencies and organizations to encourage efforts 
specifically oriented toward meeting minority health needs. 
Recognizing that communities have unique insights into their own 
health problems , DHHS should undertake activities to increase 
awareness by minority communities of the Federal ability to provide an 
overview of health problems and to provide technical assistance . 



25 



Through departmental efforts in assisting communities to define local 
health goals, objectives , and priorities, develop strategies for 
resolving health problems, and set action plans into operation, 
localities can build an internal capacity for meeting the health needs 
of local minority populations. 

Overview Position of DHHS 

The Federal Government, through DHHS, is in a unique position to 
serve as a knowledgeable resource to State and local agencies and to 
private health-related organizations. Through its efforts in data 
collection, surveillance of health indicators, research programs on 
specialized health topics, and delivery of model health services, DHHS 
retains a national overview of the health problems and demographic 
descriptors of minority populations in the United States. Examples of 
these resources include: 

• National surveys of health status and health services utilization 
conducted by the National Center for Health Statistics (NCHS) . 

• Specialized survey research, such as the National Drug Abuse 
Survey conducted by the National Institute on Drug Abuse (NIDA) , 
and the National Survey on Physical Violence in American 
Families funded by the National Institute of Mental Health (NIMH) 
and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) . 
Both surveys are oversampling Blacks and Hispanics in their 1985 
cycles . 

• The research and surveillance role played by the Centers for 
Disease Control (CDC) in areas of infant mortality, homicide 
and suicide, and diabetes. 

• Model information and educational programs in each of the six 
priority areas carried out by almost every agency. 

• Demonstration programs, such as those sponsored by the 

National Institutes of Health (NIH) that introduce proven preventive 
and therapeutic regimens and health care delivery advances to 
the public. 

Special community needs often can be identified very effectively 
at national and local levels by organizations concerned with specific 
minority subgroups. Plans for intervention will be stronger and more 
effective if they are initiated by groups that are familiar with a 
community's culture, traditions, and languages and that can mobilize 
local resources and networks for resolving particular health problems. 

Some minority communities, however, do not have sufficient 
information to define their greatest health needs and to develop 
community strategies and constructive approaches for resolving these 
problems. Where it is fitting and appropriate, DHHS can provide 



26 



states, municipalities, or communities with a national overview of 
their place within a larger context, and share the benefit of 
experience gained from programs that have proven successful in other 
localities. The Model Standards for Community Preventive Health 
Services project, a collaborative effort of CDC, the American Public 
Health Association, and associations of State, territorial, county, 
and city health officials, is a prime example of this kind of program 
activity. 

Providing Technical Assistance 

The Department can provide technical assistance to State and local 
health agencies, community- level organizations, business and industry, 
professional and voluntary health associations, and other private sector 
groups. Serving in a consultative or advisory role, DHHS experts can 
assist the states in addressing problems that lie within the state's 
jurisdiction (e.g., infant mortality, homicide, school health) by: 

• Providing specific information to allow the health community 
to take prudent action. 

• Identifying special health problems and needs. 

• Organizing and planning minority-relevant intervention approaches. 

• Suggesting mechanisms for implementing plans. 

Cooperative Efforts 

The following examples demonstrate ways the Department has worked 
with States, communities, and other organizations to build local capacity 
to meet health problems . 

Teclinicai Assistance to States. Upon request of State health author- 
ities, the Low Birth Weight Prevention Work Group will send Infant 
Mortality Review Teams (IMR teams) to conduct geographically focused 
infant mortality reviews and investigate conditions associated with 
high or changing infant mortality. The IMR teams, composed of experts 
from the public and private sectors, serve as consultants and assist 
State health departments in gaining a better understanding of local 
difficulties in reducing infant mortality, in gathering precise 
information regarding local maternity and infant health care systems, 
and in developing strategies that will provide opportunities for 
ameliorating local problems. 

Specialized Community Health Services. The On Lok Senior Health 
Services is a community-based, long-term care organization serving the 
frail elderly, many of whom are Asian. On Lok began as a 
federally funded research and demonstration project in 1972, and was 
able to assume its own financial responsibility by 1984. Services 
include hospitalization for acute conditions, a nursing home, a 
pharmacy, professional services (dentistry, optometry, podiatry, and 



27 



other subspecialty medical services), home health services, nutrition 
programs, housing for the elderly, and transportation to medical care. 
Similar specialty services have been developed in other communities 
based on the On Lok model, such as women's health, substance abuse 
programs, and youth programs. The On Lok experience indicates that it 
may be more feasible to develop specialty services in a particular 
community rather than a more comprehensive health program. 

Community Efforts. Results from research sponsored by DHHS are freq- 
uently disseminated to the general public or to target populations with 
the cooperation of national and local media, and community networks. 

The National Cancer Institute launched a special cancer 
prevention awareness program for Black Americans., It began with a 
mass media effort aimed at increasing awareness among Black citizens 
that everyone can do something to reduce the personal risk of cancer. 
The mass media effort will be followed by national and community -based 
educational activities that rely on strong involvement of 
traditionally Black organizations. 

The National High Blood Pressure Education Program has worked 
successfully with communities. State and local health departments, 
industry, and professional and voluntary health organizations to 
increase health professionals' and the public's awareness about the 
risks associated with untreated hypertension and the opportunities for 
effective treatment. 

The National Institute on Drug Abuse (NIDA) has encouraged Black 
organizations to incorporate drug and alcohol abuse prevention 
activities into their national agendas. NIDA has also provided 
guidance and support in the development and promotion of national 
multicultural networks among Black, Hispanic, Asian, and Native 
American families. One outcome is the development of a network among 
Black parents and community organizations to stimulate community-based 
prevention programs in drug and alcohol abuse. This model for a 
"grass roots" prevention program is being replicated in a select 
number of cities across the country. 

Business and industry. A number of agencies within DHHS provide 
technical assistance to individuals and organizations in business and 
industry. The Office of Disease Prevention and Health Promotion (ODPHP) 
is working with the Workplace Health Fund, a component of AFL-CIO, to 
develop worksite health promotion programs through unions. ODPHP also 
assists businesses in planning health promotion programs for the future 
by identifying trends that influence work and health. 

The National Heart, Lung, and Blood Institute (NHLBI) 
cosponsored a conference with several major corporations to examine 
positive outcomes derived from worksite health promotion programs. 
NHLBI also developed the Cardiovascular Primer for the Workplace to 



28 



assist private industry in developing cardiovascular risk reduction 
activities. At present, NHLBI is examining ways of working with small 
businesses to develop health promotion programs. 

Health Care Settings. A leader in the field of preventive 
interventions for victims of domestic violence has been the Harborview 
Medical Center in Seattle. The Center developed a comprehensive 
intervention model that addresses the needs of victims of spouse 
abuse, child sexual abuse, rape, elder abuse, and assaults by 
strangers. A model emergency room protocol for identifying adult 
victims of domestic violence has been developed for hospitals in New 
York State and can be adapted for use elsewhere. Efforts based on 
these models need to be introduced and tested further in similar 
health care settings. 

DEPARTMENTAL ACTIVITIES 

Activities in which DHHS can take a leadership role in initiating 
cooperative efforts with the non-Federal sector to improve the long-term 
health status of minority groups include: 

• Support development, testing, and dissemination of model programs 
suitable for minority community-based efforts for disease 
prevention and health promotion, especially in the six priority 
health areas. 

• Provide technical assistance in the implementation of State and 
local prevention programs that focus on the special needs of 
minority populations. 

• Increase collaborative efforts with State and local governments, 
professional associations, and health-related voluntary and private 
organizations, to develop their capacity to identify health 
objectives, set priorities, and implement strategies to improve 
the long-term health status of minority populations . This 
collaborative effort should include: 

--encouraging States to conduct reviews of their efforts to 
address the health needs of minority populations. 

--strengthening State, municipal, and local community capacities 
to develop prevention initiatives aimed at the high incidence 
of adverse health events such as drunk driving, family 
violence, and drug abuse. 

--advising States of Federal data on minorities relevant to 
their localities and encouraging the States to develop data 
on avoidable mortality by locality. 

--conducting forums through the PHS regional health offices 
where communities can present model health programs targeted 
to a particular minority health effort. A manual of these 



29 



initiatives could serve as a resource to other communities 
seeking information on effective prevention programs and 
how to apply them in different communities, 
--strengthening private and public efforts in addressing 

minority health issues by convening meetings of groups, such 
as leading private sector minority organizations, State 
health agency officers, major voluntary organizations, and 
professional organizations, to define specific minority 
health issues and to discuss mechanisms for dealing with 
them. 

--encouraging organizations concerned with minority issues to 
develop and promote health education materials that are 
appropriate to the culture and the language of the minority 
groups they serve. 

• Encourage the development of outreach programs that evaluate 
high-risk subsets of minority groups. 

• Initiate meetings with other departments in the Executive Branch 
to address health problems of mutual interest oriented to 
building the capacities of local communities. Appropriate 
topics and agencies include: 

--developing a combined strategy for prevention of homicide 
with the Department of Justice. 

--improving housing and reducing environmental hazards for 
populations at high risk for injuries with the Department of 
Housing and Urban Development. 

--coordinating smoking cessation programs and other health 
promotion programs under other Departments' sponsorship, 
such as the Departments of Defense and Education. 



30 



DATA DEVELOPMENT 



Introduction 

The Task Force believes that data issues are a major area for 
recommendations and suggests that more extensive minority health and 
illness data are needed to improve the information available to DHHS 
and the private sector for making program and policy decisions. 
Examples of why this is so include: 

• National data on mortality rates for Hispanics are lacking. 

• The accuracy with which ethnic group membership is described 
on death certificates, especially for Hispanics, is variable. 

• Studies based on diabetes mortality rates in minorities fail 

to consider differences in incidence, age of onset, availability 
of medical care, education, socioeconomic status, and 
interaction with hypertension. 

• Population-based cancer registries often lack comparability 
with information from the National Cancer Institute's 
Surveillance, Epidemiology, and End Results (SEER) program. 

• The incidence of sudden cardiac death in Blacks in relationship 
to coronary heart disease has been examined, but no firm 
conclusion is possible because of lack of data. 

Reliable data are central to measuring progress in public health, 
and are the key to assessing the current health status of the Nation 
and measuring health status trends; recognizing both sources of and 
solutions to problems; identifying health disparities between segments 
of the population; and targeting efforts directly to specific needs. 

The data available in the Task Force review and other reports have 
pointed to disparities in death rates, health status, and health care 
utilization between minorities and nonminorities , but more detailed 
data are needed to enhance our understanding of the processes underlying 
the disparity and to provide a better basis for rational program 
planning, implementing, and monitoring. The effort to obtain reliable 
data is especially challenging because minority populations are growing 
rapidly, changing rapidly, highly mobile, and, therefore, difficult 
to track yet have greater health problems than nonminorities. 

RECOMMENDATION 7: IMPROVING AND FULLY USING AVAILABLE 

SOURCES OF DATA 

DHHS should undertake activities , which would improve existing 
sources of health data, such as: enhancing cooperative efforts with the 
States in recording vital statistics , incorporating specific 



31 



racial/ethnic identifiers in data bases, and oversampling selected 
minorities in national surveys. Furthermore, DHHS should support 
innovative uses of currently available data consistent with the 
Privacy Act and confidentiality constraints . Analyses such as 
cross-comparisons from different data sets and specialized studies 
should be encouraged because they can contribute to understanding the 
health status and needs of minority populations . 

Steps to Better Understanding 

Gaining better understanding and knowledge of the health of 
minority populations requires improving the collection of quantitative 
data on the incidence and prevalence of health problems in these 
populations. Analysis of health status data with specific minority 
identifiers will allow elucidation of relationships between factors 
that may be responsible for the disparity in death rates. For 
example, the Task Force has concluded that data on the incidence of 
chronic heart disease in Black populations are inadequate because 
relatively few studies include significant numbers of Blacks. 
Recognition of these needs has led to some efforts to obtain more 
data, such as the surveillance of chronic heart disease events in a 
predominantly Black community being performed under the sponsorship of 
NHLBl. Similarly, the Hispanic Health and Nutrition Examination 
Survey (HHANES) will advance knowledge of health and nutritional 
status among Americans of Mexican, Puerto Rican, and Cuban origin 
through special data collection efforts. Until this survey, data on 
the health status of Hispanics were limited to self-reports such as 
those compiled in the National Health Interview Survey (NHIS) . 

Sources of Health Data 

DHHS receives health data on a variety of topics from a wide 
range of sources. Vital statistics data on births, deaths, marriages, 
and divorces are provided by the States to the National Center for 
Health Statistics (NCHS) , the Nation's chief health data collection 
agency. NCHS also conducts national surveys based on samples that are 
representative of the total U.S. population. These surveys include 
NHIS, the National Health and Nutrition Examination Survey (NHANES) , 
the National Ambulatory Medical Care Survey (NAMCS) , the National 
Hospital Discharge Survey (NHDS) , and other data collection activities 
that document the health characteristics of the United States 
population. Other data on health status and health care utilization 
are furnished by States and local sources to the Centers for Disease 
Control (CDC) , to the Health Care Financing Administration (HCFA) 
through its Medicaid and Medicare programs, to the Social Security 
Administration (SSA) , and to various programs within the Department 
that may be studying health problems within specific populations. 



32 



Problems with Existing Sources of Data 

The data now collected by the Department comprise a useful base 
for health-related study and analysis. The Task Force, however, has 
identified a number of problems with existing data relating to the 
health of minorities. 

One problem is the lack of common practices among the States in 
recording ethnicity identifiers in their reported data. Few States 
require a Hispanic identifier on death certificates, and the quality 
of the identifications that are made is variable. Furthermore, 
individuals who fill out death certificates may do so inadequately 
because of insufficient training and understanding of the importance 
and uses of the information. 

When race and ethnicity are recorded in Federal data collection 
efforts or for administrative record keeping, the Office of Management 
and Budget (0MB) provides minimum requirements for the categories to 
be recorded. The Office of Federal Statistical Policy and Standards 
Directive Number 15 classifies race as: 1) American Indian or Alaska 
Native, 2) Asian or Pacific Islander, 3) Black, and 4) White. 
Ethnicity is defined as: 1) Hispanic origin, or 2) Not Hispanic 
origin. 

Although these categories, as mandated, are too broad to permit 
delineation within subgroups, the greater difficulty is that many DHHS 
statistical files and data bases fall short of meeting even the OMB 
requirement, particularly administrative records, self-reported 
hospital forms, and some social security claims. Furthermore, some 
DHHS data bases that originally contained data specifying minority 
group status have aggregated that data into a category labeled 
other", thus losing the racial/ethnic integrity of the data. 

Another problem relates to data collected from national surveys. 
Current surveys provide a good indication of the health picture of the 
Nation as a whole, as they are designed to do, but only limited 
information is available from them for many minority populations. 
Surveys usually sample minorities in proportion to their presence in 
the U.S. population. More data exist on Blacks, as the 
largest minority group and, indeed, NCHS has data on Blacks going back 
to the 1960's, the earliest period for which tapes are available. 
Smaller groups, such as Native Americans or Asian/Pacific Islanders, 
are represented by far fewer households. National surveys may include 
too few minority individuals to permit reliable analyses of health 
data for a particular group. 

The Task Force has concluded that inconsistencies in data 
collection practices among the States, such as inadequate recording of 
some ethnic identifiers, overaggregation of minority data, and 
insufficient representation of minorities in national surveys are 
areas needing improvement . 



33 



strategies for Improving Data 

Two strategies for improving data on minorities are oversarapling 
and targeted studies . Both approaches have advantages and 
disadvantages that need to be weighed when planning data collection 
efforts . 

Oversampling of minorities offers the advantages of improving the 
precision of the data and allowing comparison with other groups for 
which data were collected contemporaneously. Oversampling in national 
surveys, however, presents the problem of developing valid and 
reliable procedures to select a randomized, representative sample of 
minorities. Moreover, additional costs are involved in oversampling 
in a national survey. Thus, there is a trade-off between costs and 
precision of information. 

Another strategy for obtaining improved data is to mount targeted 
studies of specific minority populations or geographical areas. This 
technique would enhance knowledge of an identified group without the 
cost and difficulty of a national sample. By virtue of their targeted 
focus, however, such studies yield data that may not necessarily be 
comparable to other populations. Thus, careful planning is necessary 
to ensure that meaningful comparisons can be made. 

The choice of sampling strategy is influenced by the issue being 
addressed, the needed degree of oversampling and its attendant costs 
and complexity, the geographic concentration of minority groups, and 
other considerations. Although oversampling or targeted studies may 
correct deficiencies in national surveys, the technique selected must 
be tailored to the particular data-gathering effort. 

Using Existing Data 

Many agencies in DHHS and other Federal Departments routinely 
collect information for administrative and other programmatic purposes 
that may contain health or ethnic identifying data. Presently, 
legislative restrictions that protect the privacy of individuals 
prohibit the exchange of administrative data for statistical research 
purposes. A solution to this dilemma is to establish conditions for 
the greater linkage of records among agencies to be used only for 
statistical research purposes. The rights of individuals to privacy, 
however, must be protected. Record linkage is one effective way to 
obtain needed information on small populations without great cost. 

Record linkage has been supported consistently by DHHS in the 
past. Because of the tremendous wealth of information on minority 
health that could be gleaned from administrative records in this and 
other Departments, an appropriate resolution should be explored. 



34 



DEPARTMENTAL ACTIVITIES 

To enhance the opportunities for more effective data collection 
relating to minorities in the United States, DHHS should pursue the 
following activities: 

• Assign high priority to cooperative efforts between DHHS and the 
States directed at developing standardized Hispanic identifiers 
in vital statistics records (death, birth, marriage, and divorce 
certificates) . 

• Strengthen and expand efforts between the Department and the 
States to develop a national data base of linked birth and 
death records for analyzing infant mortality. 

• Strengthen and expand cooperative efforts to train personnel to 
complete vital statistics records accurately (particularly with 
regard to correct coding of causes of death and racial/ethnic 
identifying items). 

• Establish a mechanism to evaluate the quality of information on 
death certificates to determine if guidelines for completing the 
items on the certificate are followed. 

• Require all DHHS agencies that collect health data from in- 
dividuals to include race and ethnic identifiers, as defined by 0MB. 
Where possible and desirable, further breakdown within racial and 
ethnic categories should be recorded, e.g., national origin of 
Hispanics and Asian/Pacific Islanders. 

• Maintain specific racial/ethnic identifiers when processing 
original data. For those data collected cooperatively from 
the States by agencies such as CDC and NCHS, efforts should be 
increased to overcome barriers to obtaining data with standardized 
race/ethnicity identifiers. 

• Oversample selected minorities in national surveys of health 
indicators or conduct targeted studies on minority health 
problems, as appropriate. 

• Work with the Census Bureau to improve health-related, minority- 
specific data collection for the 1990 census. 

• Analyze and highlight minority health issues, especially in the 
six health priority areas, that result from improved minority 
identifiers in data collection. 



35 



Develop mechanisms for matching individual records from among 
government data sets, within and between Departments, for 
health and statistical research purposes. DHHS should 
encourage and support legislative changes to allow such 
matching to occur with the appropriate safeguards. 

Investigate, in the absence of legislation permitting data 
linkage across DHHS agencies, mechanisms whereby the minority- 
specific, health-related data collected by each agency can be 
analyzed and published. 



36 



RESEARCH AGENDA 

Introduction 

The Task Force has reviewed a considerable body of scientific 
knowledge related to the disparities in health status between minority 
and nonminority populations in the United States. It is evident that 
most of the disparity can be attributed to six areas identified as 
major contributors to excess mortality among minorities. Although the 
Task Force Subcommittees have explored physiological, cultural, and 
societal factors that may be responsible for the health disparity, 
many unanswered questions remain. Resolving these questions will 
require continued research and analysis to increase the base of 
scientific knowledge and to elucidate factors that put minorities at 
greater risk for illness and death. 

The research activities recommended by the Task Force refer 
primarily to needed minority-specific health issues. The huge volume 
of ongoing research, particularly basic research already conducted 
through DHHS, applies to all populations, including minorities. 
Research into the etiology of diseases, treatment of diseases, and 
improved health service delivery will continue to benefit all 
Americans. The research proposed by the Task Force, however, is of 
major importance to minority health because it specifically aims at 
understanding the reasons underlying the longstanding disparity of 
health status in the United States. It offers the means to prevent or 
reduce much of the illness and death experienced by minorities in 
disproportion to their representation in the American population. The 
spectrum of suggested activities includes research into the etiology 
of diseases, research in behavioral and social sciences, clinical 
studies of treatment and treatment outcomes , research on the dynamics 
of health care and its impact on disease, and appropropriate 
interventions for disease prevention and health promotion. 

The research agenda presents examples of priority areas for 
immediate investigation. The Subcommittee reports provide a rationale 
and fuller elaboration of the recommended research activities. By no 
means do they exhaust the range of activities needed for further 
research into minority health. 

In addition to research into the reasons for the disparity, 
separate studies need to evaluate the impact of DHHS and other Federal 
programs on the health of minorities. Such studies are needed to 
coordinate departmental policies and programs, to identify areas where 
program efficiency can be improved and costs reduced, and to provide a 
measure of the extent to which policies and programs are achieving 
their objectives. Recognizing this, the Task Force includes 
evaluation studies as an integral part of the research agenda. 



37 



The Task Force suggests that each agency of DHHS review its 
portfolio of federally supported research and its applications for 
research funding to ensure that minority health issues are included. 

RECOMMENDATION 8: RESEARCH AGENDA 

The Department should adopt and foster a research agenda to 
investigate factors affecting minority health and should incorporate 
appropriate research activities on minority health into ongoing 
research programs consistent with the referral guidelines of each DHHS 
agency. The Task Force considers the following areas to be of major 
Importance for research : 

• Risk factor ident if icat ion 

• Risk factor prevalence 

• Health education interventions 

• Preventive services interventions 

• Treatment services 

• Sociocultural factors and health outcomes 



DEPARTMENTAL ACTIVITIES 

I. Research into Risk Factor Identification 

Risk factors are the characteristics of individuals that are 
associated with the occurrence of health problems . Their identification 
is important to elucidate possible etiologic factors for a disease, 
to identify individuals or populations likely to experience health 
problems, to institute early preventive measures, and to identify groups 
on whom preventive or educational interventions can be concentrated. 

More information is needed to clarify whether risk variables that 
contribute to the occurrence of disease in White populations contribute 
to disease differently in minority populations. For example. Black 
males have a higher prevalence of hypertension than Whites but experience 
a similar rate of mortality from coronary heart disease (CHD) as White 
males. Similarly, some Hispanic subgroups, specifically Mexican Americans, 
have a higher prevalence of diabetes, another risk factor for CHD, but 
exhibit lower mortality rates from CHD than Whites. 

For the most part, identifying risk factors, defining risk status 
(whether a person is at high or low risk for a health problem) , 
establishing risk profiles (distribution of risk status in a 
population), and following trends in risk patterns can be accomplished 
by well-designed epidemiologic studies. The impact of behavioral, 
physiological, and environmental factors also can be assessed in such 
studies . 

Certain minority groups, such as second-generation Chinese, have a 
more favorable health status for certain conditions or have reduced 
all-cause mortality. Studies of populations at low risk for certain 



38 



diseases also will add to understanding the relationship of risk 
factors to disease. DHHS activities to identify risk factors for the 
major health priority areas include: 

• Identify and quantify, where possible, behavioral, physiological, 
and environmental risk factors for CHD, cancer, and diabetes in 
each minority group. Determine if the risk factors for CHD 
identified for White populations act similarly in the minority 
groups or if other risk factors, not yet identified, contribute 
to CHD in minority groups. 

• Identify behavioral, physiological, and environmental 
characteristics of minority groups that place them at higher 
risk for any of the six health priority areas. 

• Assess the impact of hypertension as a risk factor for morbidity 
and mortality in all minority groups. 

• Identify the determinants of smoking behavior, cessation, and 
cessation maintenance in minority populations, particularly 
among pregnant minority women. Blacks, Hispanics, and Native 
Americans who may suffer the delayed effects of increasing 
rates of smoking. 

• Determine the relationship of high rates of obesity found in 
Black females to their consequent excess mortality from CHD. 

• Investigate the role of high-density lipoprotein (HDL) levels 
in influencing CHD outcome in Black and other minority males. 

• Investigate links between dietary potassium and sodium intake 
(and other electrolytes) and hypertension in Blacks and other 
minorities . 

• Study variables such as income, employment, school truancy, drug 
and alcohol problems, educational attainment, and accessibility 
of handguns as possible risk factors for homicide, particularly 
among Black and Hispanic males. 

• Support improved studies of situational correlates of homicide and 
nonfatal assaults aimed at identifing high-risk situations for 
which preventive interventions are needed. 

• Support studies on risk factors for deaths from unintentional 
injuries, suicide, and homicide among Native Americans and 
other minorities. 

• Support studies on risk factors for suicide among Asian women, 
particularly those of age 45 and older. 



39 



• Investigate generational factors related to birthweight since 
the birthweight of the offspring appears to be correlated with 
the weight of the mother at her birth. Investigate racial/ethnic 
differences and socioeconomic resources related to differences 

in birthweight. 

• Elucidate the role of physiological, social, psychological, 
and environmental stress on pregnancy outcome in different 
racial/ethnic groups, for example, the effects of unplanned 
pregnancy, unmarried status, low economic status, and employment 
in physically stressful jobs. 

• Study the influence in Black women of nutrition as a risk 
factor for cancer, cardiovascular disease, and low-birthweight 
offspring. 

• Conduct studies to understand dietary and exercise patterns more 
thoroughly in the four minority groups . 

• Focus research efforts on the preventable causes of postneonatal 
mortality, including causes of accidental death. Research should 
encompass the interrelationship of individual and family 
behaviors, and health care delivery factors that influence the 
use of well and sick baby care, and immunization of babies. 

• Initiate descriptive studies to identify occupational risks 
associated with the leading causes of death and disability in 
minority populations. 

• Investigate minority status as a risk factor for safety in the 
workplace, including monitoring excessive exposure to contaminants 
from occupational sources and environmental pollution. 

• Assess factors contributing to excess deaths due to cardiovascular 
disease in Native American men aged 35-39 years old. 

II. Research into Risk Factor Prevalence 

Disease patterns may be shared by an entire minority population, a 
subset of that population, a certain age group or gender, or geographic 
grouping of the minority population. Risk factor prevalence in such 
groups which share a health status trait warrant careful investigation, 
not only in cases where a clear disease burden is evident but also for 
diseases in which a subgroup displays better health. Activities to 
study risk factor prevalence for the major health priority areas should 
include : 

• Continue to support large-scale, population-based prospective 
studies of coronary heart disease, similar to the Framingham 
studies and/or community-based studies for minority 
populations. Among the many Hispanic subgroups, Puerto Ricans 



40 



and Cubans living in the United States have not been studied 
extensively and particularly warrant such research. Sudden 
death rates from CHD among Blacks need to be investigated by 
age and gender. Surveillance of the offspring of individuals 
studied is needed to understand coronary disease trends and to 
elucidate familial contributions to the incidence and disease 
process in these population groups. 

• Study serum lipid levels, dietary risk reduction information, 
interventions, and behaviors for Puerto Rican, Cuban, and 
other Hispanic populations. 

• Assess the relationship between dietary patterns in minority 
groups and the development of diabetes, cancer, and cardio- 
vascular disease (CVD) . Strengthen nutritional status surveillance 
of low income minority populations. 

• Design epidemiologic studies to evaluate differences in the 
distribution of diabetes in minority groups and the 

impact of physiologic variables on these differences. Study 
etiology of diabetes using diabetes blood group analysis, 
particularly for American Indians. 

• Support cohort studies to gain more insight into the etiology 
of drug abuse among minorities. 

• Examine smoking prevalence and industrial exposures as contributing 
to CVD and the rapid rate of increase in lung cancer in Blacks. 

• Examine factors associated with unplanned pregnancies, including 
both nonuse and inadequate use of contraceptives, in high-risk 
minority women and teenagers. Unplanned pregnancies are 
associated with worse patterns of prenatal care and higher 
rates of low birthweight. 

• Investigate the prevalence of multiple risks (e.g., smoking 
and drug abuse) among different minority populations to 
understand possible synergistic effects on pregnancy outcome. 

• Initiate prospective studies on perinatal outcome (low birth- 
weight and infant mortality) . 

III. Research into Health Education Interventions 

Health education interventions are directed at improving the 
awareness of individuals and communities about controllable risk 
factors associated with the causes of excess death and disability. 
Components of the major health problems facing minorities that are 
amenable to health education efforts include the misuse of alcohol 
and drugs, use of tobacco, dietary habits, exercise, stress 
management, compliance with medical regimens, and appropriate use of 
preventive services. It is not always clear, however, which type of 



41 



intervention is best suited to the target audience and what kinds of 
outcomes should be expected from efforts to promote intervention 
strategies for minorities. Activities for investigating health 
education interventions include: 

• Develop health education techniques appropriate to particular 
minority groups that will facilitate the adoption of specific 
interventions for risk factors, especially among groups at 
high risk for cardiovascular disease, cancer, diabetes, and 
homicide. Such research should recognize different cultural 
sensitivities and attitudes toward health behaviors related to 
these problems. 

• Support research to develop and validate effective stress 
reduction and behavior modification strategies for treatment of 
coronary heart disease and its risk factors in minority 
populations . 

• Develop model programs for use in community-based efforts to 
prevent homicide and improve delivery of services to victims 
of violence, such as the House of Umoja. 

• Support studies among minority groups to identify existing 
health beliefs and practices more accurately. 

• Analyze factors associated with positive perinatal health 
outcomes among Asian Americans to help identify ways to avoid 
adverse outcomes for other minority populations. 

• Identify effective health education interventions for minority 
groups in the areas of dietary risk factor reduction, 
nutritional counseling, exercise, and smoking cessation. 

• Support impact .and outcome evaluations of minority health 
education interventions to help plan or modify interventions 
and to justify the allocation of resources to such projects. 

• Elucidate specific characteristics of minority populations that 
may influence the dissemination of health information. 

• Examine different methods of approaching minority populations, 
through schools or worksites, to effect behavior change for 
developing positive coping strategies. Explore differences 

in coping strategies between males and females. 

IV. Research into Preventive Services Interventions 

Maintenance of health and prevention of disease are major 
challenges to both the individual and the health community. To meet 
the challenge, rigorous prevention-oriented research should be 
initiated commensurate with the levels of need and representation of 
minority populations. Components of effective disease prevention and 



42 



health promotion interventions that address minority health concerns 
and methods that build on the strengths of both urban and rural 
families and communities are among the activities stressed in this 
section. Research activities include: 

• Assess the factors influencing compliance/noncompliance to 
antihypertensive medication regimens, especially in Filipino 
women. This group contrasts with other ethnic minority groups 
in the United States in which women generally have better blood 
pressure control than men. 

• Design and support studies to develop prevention methodologies 
especially in the areas of alcohol and drug abuse as well as in 
each of the health priority areas. Assess the success of 
prevention and treatment strategies for alcohol and drug abuse 
in minority populations. 

• Conduct evaluation studies to assess the impact of innovative 
approaches to prevent adverse pregnancy outcomes, especially 
for minority women. Sociological, behavioral, and biological 
variables should be controlled. 

• Investigate the usefulness of expanded screening programs among 
minority groups, e.g., blood glucose screening in those over 
age 50 for diabetes, hepatitis B screening for pregnant Asian 
women, screening newborns for sickle cell disease, and sonography 
for Black women at increased risk for multiple gestations. 

• Determine the mechanisms by which pregnancy planning influences 
prenatal care, birth outcomes, and infant well-being. 

• Track victims of serious nonfatal violence (e.g., child abuse, 
spouse abuse, assault) because these may be events preceding 
homicide. 

• Explore mechanisms for reimbursing counseling and patient 
education services provided under Medicare and Medicaid programs. 
Continue to develop demonstration programs, particularly those 
that serve minority populations, to identify the best means 

for reimbursing health education programs provided in clinical 
settings . 

• Assess usefulness of clinical settings to offer counseling to 
minorities for key health behaviors. 

• Support studies to identify beliefs, awareness, and prehospital 
behavior that might potentially delay diagnosis and treatment of 
cardiovascular disease, cancer, diabetes, and other conditions 
in minority patients. 



43 



V. Research into Treatment Services 

Favorable health outcomes are related to accurate diagnosis, 
appropriate and timely therapy, and follow-up. Understanding the 
factors in primary health care settings that influence diagnosis and 
treatment of minorities is important in developing intervention 
approaches. Research is needed into the factors that operate in 
medical care settings including: the dynamics of the patient-provider 
relationship; the behavior, beliefs and attitudes of minority patients 
and health care providers; and patterns of treatment/medical care 
provided to minorities. Specific research activities follow: 

• Assess determinants of physician behavior that influence 
patient interaction, follow-up, and the adoption of innovative 
techniques for prevention, early detection, and treatment. 

• Determine how specific patterns of increased risk factors or 
preexisting conditions determined to be more common among 
minorities influence treatment approaches. 

• Develop methods to monitor coronary heart disease events that 
occur in the community, such as: sudden death, hospital admissions 
and discharges of patients diagnosed as having heart disease, 

and emergency room visits for patients with chest pains and 
related complaints. 

• Evaluate the long-term efficacy and safety of antihypertensive 
medications, particularly in Blacks. 

• Identify delivery systems to facilitate the recruitment of 
hard-to-reach pregnant women into early care programs. 

• Continue to evaluate the effect on perinatal outcomes of major 
programs such as Maternal Infant Care, Improve Pregnancy Outcome, 
and Supplemental Food Programs for Women, Infants, and Children. 

• Elucidate how health service patterns and individual behavior 
during illness affect cancer incidence, survival, and mortality 
of minorities. 

• Develop model programs to foster participation of State and 
Federal efforts in diabetes control. 

• Study the specific components of prenatal care that have the 
greatest potential for preventing untoward perinatal complications. 



44 



VI. Research into Sociocultural Factors and Health Outcomes 

Sociocultural factors play an important role in the maintenance 
of health, perception of illness, and/or the pattern of treatment 
sought by the individual. Many factors such as cultural heritage, 
socioeconomic status (SES), social support, knowledge attitudes, 
and health practices interact to affect health status. Furthermore, 
sociocultural factors may vary over time with other factors such as 
acculturation, economic and employment changes, age, or immigration 
patterns that affect either an individual or an entire group. These 
complex interrelationships can only be addressed through 
multidisciplinary research that investigates factors beyond those 
in a traditional biomedical model. Specific research activities 
include: 

• Develop valid and reliable measures of acculturation and socio- 
cultural indices that are sensitive to shifts in beliefs, values, 
and behavior patterns that might increase CHD risk in Native 
Americans. Similar measures should be developed for other 
diseases for which other minority populations have an increased 
risk of mortality. 

• Study tribal variations in diabetes among middle-aged and 
older American Indians. 

• Investigate SES as a risk factor for CHD, hypertension, stroke, 
hypertension-related end-stage renal disease, and cancer in 
all minority groups. Investigate minority subgroups who appear 
to have higher risk profiles and who actually display lower 
CHD mortality rates. 

• Continue research on the association of social mobility and social 
status with CHD and other disease categories in minority populations, 

• Focus studies on the link between economic conditions and infant 
mortality, including sociocultural factors that may help to 
explain the relatively good outcomes in infant mortality seen 

in the Asian, American Indian, and Alaska Native populations. 

• Support research to characterize the experiences, attitudes, and 
beliefs among minority women who tend not to seek or continue 
prenatal medical care. 

• Conduct research into the role of traditional folk medical 
practices among minority populations and its effect on health 
outcomes . 

• Conduct descriptive studies to examine the relationship between 
level of acculturation, the influence of cultural beliefs, 
values, and behavior patterns in the maintenance of health, 
development of illness, and pattern of treatment in minorities. 



45 



Accounting For the 
Health Status Disparity 




SOCIAL CHARACTERISTICS OF MINORITY POPULATIONS 



Introduction 

Among the many factors presumed to influence minority health 
status in the United States today, four social characteristics are 
believed to be especially significant: (1) demographic profiles, (2) 
nutritional status and dietary practices, (3) environmental and 
occupational exposures, and (4) stress and coping patterns. 

The demographic profiles of Blacks, Hispanics , Asian/Pacific 
Islanders and Native Americans differ considerably from those of the 
nonminority populations (see Tables 2, 3, and 4). Marked differences 
also exist among the four groups and within each group. For example, 
native-born versus foreign-born status, age at time of immigration, 
and degree of acculturation are important variables within the 
Hispanic and Asian American populations. Dietary patterns and 
practices are similarly group-specific and fluctuate with the extent 
to which immigrants have adopted nonminority eating habits and food 
preferences . 

Because high percentages of minorities are city dwellers, with 
high concentrations living in the inner cities, they are exposed to a 
relatively greater number of environmental hazards, including 
pollution, traffic hazards, substandard and overcrowded housing, and 
crime. Occupational risks faced by minorities are higher than those 
confronting nonminority group members because a higher proportion of 
minority individuals are employed in positions that potentially 
present greater levels of exposure to environmental risks, such as 
physical and mental stressors, and toxic substances. 

Finally, the unique patterns of exposure to stressors and ways of 
dealing with stress and adversity in minority groups may play a 
crucial role in health outcome. An increasing body of research 
suggests that the ways an individual copes with stress and the 
resources available to resolve stressful situations, rather than the 
stressor itself, play the more important role in health outcome. In 
some minorities, traditional folk beliefs and culturally specific 
family patterns may affect their ability to withstand social, 
economic, and psychological stressors. 

The following sections outline some of the demographic data, 
nutritional and dietary patterns, environmental and occupational 
risks, and behavior patterns that may influence the health status of 
minorities in the United States. Although the data on social 
characteristics of minorities are compared with those of 
nonminorities , each minority is discussed separately with few 
comparisons to the other minority populations. 



47 



Table 2 



Percent Distribution of Persons by Ethnic/Racial 
Background and Sex, Age, and Geographical Area 
United States, 1980 



Characteristic 


Ethnic/Racial 


Background 










White 


Black 


Hispanic 
Origin 


Other 


Total 


Total 


79.6 


11.5 


6.4 


2.5 


226,545,805 


Sex 












Male 


79.7 


11.2 


6.6 


2.5 


110,053,161 


Female 


79.5 


11.8 


6.3 


2.4 


116,492,644 


Age 












Median Age* 


31.6 


24.9 


23.2 


26.5 


30.0 


Under 15** 


73.0 


15.0 


9.0 


3.0 


51,290,339 


15-44** 


79.0 


12.0 


7.0 


3.0 


105,203,337 


45-64** 


84.0 


9.0 


4.0 


2.0 


44,502,662 


65 -h** 


88.0 


8.0 


3.0 


1.0 


25,549,427 


Geographic Area 












Region 












North East 


83.4 


9.6 


5.3 


1.7 


49,135,283 


North Central 


87.5 


9.0 


2.2 


1.3 


58,865,670 


South 


74.3 


18.4 


5.9 


1.3 


75,372,362 


West 


73.5 


5.1 


14.5 


6.9 


43,172,490 


Urban 


76.1 


13.3 


7.9 


2.8 


167,050,992 


Rural 


89.4 


6.5 


2.5 


1.6 


59,494,813 



SOURCE: General Population Characteristics, United States Summary, 1980 Census of Population. U.S. Department of 
Commerce, Bureau of the Census. Issued May 1983. 
♦Note that the median age is given in years for each racial/ethnic group (and total) and is not a percent distribution. 
**Percent distribution is rounded to nearest whole number. 



48 



Table 3 



Percent Distribution of Persons of Nonminority and 

Minority Background by Number, Sex, and Geographic Distribution, 

United States, 1980 



Characteristic 

Total 
Male 
Female 



Ethnic/Racial Background 



Nonminority 



79.6 
79.7 
79.5 



Minority 



20.4 
20.3 
20.5 



Total 



226.5 
110.0 
116.5 



Geographic Area 
Region 
Northeast 
North Central 
South 
West 



83.4 
87.5 
74.3 
73.5 



16.6 
12.5 
25.6 
26.5 



49.1 
58.9 

75.4 
43.2 



Urban 
Rural 



76.1 
89.4 



24.0 
10.6 



167.1 
59.5 



NOTE: Percent distribution is rounded to nearest tenth. 

SOURCE: General Population Characteristics, United States Summary, 1980 Census of Population. U.S. Department of 
Commerce, Bureau of the Census. Issued May 1983. 



49 



Table 4 



Occupational Distribution of Minority Groups 
Ratio of Nonminority to Minority* 



Occupation 



Sex: 



Black 



M 



Asian 



M 



Native 
American 



M 



Hispanic 



M 



White Collar 



1.39 1.59 1.03 .96 1.50 2.04 4.70 



Blue Collar 



.77 .85 



.88 1.42 



.68 



.77 1.54 



Farm 



1.56 1.08 1.20 1.03 



.78 



.66 



Service 



.56 



.49 1.03 



.35 



.57 



.57 



.13 - 



Employed 



1.08 1.07 1.90 1.39 2.95 



1.82 



SOURCE: Department of Commerce: A Statistical Analysis. Women in the United States. Series P-23, No. 100. 
Washington, D.C. 

*Represents the ratio of nonminority to minority. For example, 39 percent more nonminority males are in white collar 
occupations than are Black males. 



50 



Social Characteristics of Blacks 

The 1980 report of the Bureau of the Census indicates that one 
out of every five persons in the United States is a member of a 
minority group. Blacks are the single largest minority group, 
constituting 11.5 percent of the total population of the country. The 
number of Blacks in 1980 was 26.5 million, an increase of 
approximately 17 percent over 1970 Census figures. The distribution 
of Blacks compared with Whites is different within age categories. At 
age 15 or under. Blacks constitute approximately 15 percent of the 
total population, while by age 64, their relative proportion has 
declined to 8 percent. 

Nearly 59 percent of all Blacks lived in the central cities in 
1980, although increasing numbers were living in nonrural areas 
outside these cities. Cities with the largest number of Blacks are 
New York, Chicago, Detroit, Philadelphia, and Los Angeles. Migration 
of Blacks from the South not only slowed but slightly reversed during 
the 1970's; nonetheless, 53 percent of all Blacks still reside in the 
southern region of the country. 

The median age of Blacks is 24.9 years. The life expectancy in 
1983 was 65 years for men and 74 years for women, contrasted to 72 
years and 79 years for White men and women, respectively. The 
age-adjusted mortality rate per 1,000 population for Blacks is 7.7; 
for Whites , 5.3. 

Black families are on the average slightly larger than 
nonminority families, with the average Black family comprised of 3.7 
members. Although total birth rates among all groups have dropped 
since 1970, the overall rate of childbearing is still higher among 
Black women than among women of nonminority groups, currently 
averaging 2.3 births per woman for Blacks and 1.7 for nonminority 
women. The percent of Black households headed by women (37.7 percent) 
is more than three times higher than that of nonminority households 
headed by women (10.9 percent). 

Seventy-nine percent of Blacks have completed a high-school 
education, and 13 percent are college graduates. The median income of 
Black families in 1981 was $13,270; nonminority median family income 
was approximately $10,000 higher. One of every three Blacks (34 
percent) lived below the poverty level in 1981. This rate was 
consistent with that of Hispanic and Native Americans but 
substantially higher than that of nonminorities, among whom the rate 
was 11 percent. Unemployment among Blacks in 1982 was 18.9 percent. 
This was more than double the nonminority unemployment rate of 8.6 
percent . 

There is no single dominant dietary pattern among Black 
Americans. Generally, dietary patterns may be subdivided into 
southern versus nonsouthern, urban versus rural, native-born versus 



51 



foreign-born, and Christian versus Muslim. Many of the unique dietary 
patterns among Blacks are influenced by historical and regional food 
availability and food preparation practices. For example, among 
Blacks living in the southern region of the United States, diets may 
include a preference for vegetables, grain and grain products high in 
carbohydrates, and organ meats high in cholesterol. 

Although there is a relatively high rate of meal skipping and a 
lower use of vitamin and mineral supplements among the Black 
population, there are no data that suggest major differences between 
Blacks and nonminorities today with regard to the proportion of 
calories consumed from carbohydrates, proteins, and saturated and 
unsaturated fats. Generally, Black diets are rich in sources of 
vitamin A, predominantly from green leafy vegetables, and in protein 
derived from poultry, fish, and dried beans. Blacks tend to consume 
fewer dairy products than do nonminority group members, possibly 
related to a higher rate of lactose intolerance among Blacks than 
Whites. Salt consumption is high; however, excessive salt intake is 
also a dietary risk factor in the diet of nonminority groups. 

Breast feeding is less common among Black women than among 
nonminority women, with the exception of women from the Caribbean 
countries among whom breast feeding is more common. Some research has 
shown that pica (a craving for nonfood substances such as clay) is 
fairly common in Black women of the rural South. A significant 
nutritional risk among Blacks is the marked prevalence of obesity 
among Black women compared with nonminority groups. There is no 
evidence of extensive prevalence of growth stunting among Black 
children. 

In general, Blacks have higher rates of morbidity and mortality 
from unintentional (accidental) injuries such as poison ingestion, 
asphyxiation resulting from faulty heaters, and drowning than do 
nonminority members. Blacks also have a much higher death rate from 
housefires than do nonminority group individuals. Differences in 
nondisease mortality and morbidity rates, however, are diminished with 
adjustment for income. 

Black women have approximately the same rate of participation in 
the work force as nonminority women, while the rate for Black men is 
slightly lower than that of nonminority men. Black women have a 39 
percent greater chance of sustaining job-related disease and serious 
work-related injuries than nonminorities. Blacks have a 25 percent 
greater chance of dying from such causes than nonminorites . Blacks in 
the work force are highly concentrated in three of the six major 
occupational groups: operators, fabricators, and laoorers (27 
percent); technical, sales, and administrative support (24 percent); 
and service occupations (23 percent) . Blacks are consistently 
underrepresented in managerial and professional specialty occupations, 
where they constitute 6 percent of the work force. 



52 



A review of the family and behavior patterns of Blacks reveals 
that among the Black populations, kinship and family ties are 
extremely important. These ties often form the basis of a network of 
mutual support that can provide material, emotional, and social 
resources to family members in distress. Also, the church is a 
powerful source of emotional strength for many Blacks and their 
families. Folk beliefs about health and illness may have have varying 
effects on how an individual reacts to signs and symptoms of poor 
health. However, little is known about folk beliefs among Blacks or 
the extent to which Blacks rely on folk remedies. Research on the 
relationship between health beliefs and illness behavior suggests that 
such differences may assist in explanation of patterns of health care 
for some minorities. 

Social Characteristics of Hispanic Americans 

Hispanic Americans numbered 9.1 million in 1970 and 14.6 million 
in 1980, a 61 percent increase within the decade. By 1983, the 
Hispanic population in the U.S. had reached 15.9 million. Mexican 
Americans constituted nine million, or nearly two-thirds of this 
total, followed by Puerto Ricans (two million), and Cubans (one 
million). All told, Hispanic Americans constitute 6.4 percent of the 
population of the United States. The more than three million Puerto 
Ricans residing in Puerto Rico are not included in these figures, 
since they are treated separately by the Census Bureau. 

Sixty percent of all Hispanics live in Arizona, California, 
Colorado, New Mexico, and Texas. Half of the total live in two states, 
California and Texas. The Hispanic population showed signs of greater 
geographic dispersion during the 1970s, most notably to New York, 
Illinois, and Florida. Half of all Cuban Americans live in Florida. 
One out of two Hispanic Americans lives in the inner city of 
metropolitan areas, and they are heavily concentrated in the larger 
cities, i.e., those with a population of one million or more. 

Hispanics are generally a youthful population. In 1980, 20 
percent were less than ten years of age, contrasted to 14 percent for 
the country as a whole. Conversely, only 3 percent of Hispanics were 
more than 70 years of age, as opposed to 7.7 percent of nonminorities . 
The median age of Hispanic Americans is 23 years. 

Hispanic Americans have a relatively high fertility rate; the 
number of children per family is 2.3. Twenty-three percent of 
Hispanic households are headed by women; among Puerto Rican families, 
the rate is 40 percent. Forty-nine percent of Hispanic women are in 
the work force. Fifty-eight percent of Hispanic Americans have 
completed a high-school education; this number is more than 20 
percentage points lower than that of the Black population. One out of 
every ten Hispanic Americans holds a college degree. 



53 



The median family income for Hispanic Americans in 1981 was 
$16,228. Thirty percent of all Hispanics were living below the 
official poverty level in 1982, and 13.8 percent were unemployed. 

The variation in dietary practices among Hispanic Americans 
reflects the diversity of backgrounds among this subset of the 
population. Certain similarities, however, may be seen; these include 
a relatively higher reliance on vegetable protein sources rather than 
on meat sources. Grains and grain products are dietary staples. 
Green leafy vegetables are not a typical part of the diet. 
Consumption of dairy products is relatively low. 

Food consumption and preparation practices common among Hispanics 
of Mexican, Puerto Rican, and other backgrounds are generally adequate 
to provide all needed nutrients. Fiber consumption is high. Animal 
fat content is substantial, but it is roughly equivalent to that of 
the typical nonminority diet. 

Several authors have reported concern over the high sodium and 
high carbohydrate content of many Hispanic diets . Studies also have 
shown an excessive prevalence of growth stunting in Hispanic children, 
especially among those two to five years old. This problem is more 
severe among children not born in the United States than it is among 
native-born Hispanic children. Growth stunting is also more prevalent 
among children of lower income families. It has been suggested that 
the incidence of chronic disease such as diabetes mellitus is related 
to overnutrition and obesity in Hispanics. 

A large proportion of Hispanics work in blue collar, service, or 
agricultural occupations. The shift from rural, unskilled labor to 
blue collar work has not been accompanied by a rise in socioeconomic 
position. Hispanic Americans are overrepresented in positions in the 
manufacturing and construction industries, which report the first and 
second greatest number of work-related injuries, respectively. They 
also are overrepresented in farming and in metal mining, two 
additional high-risk employment areas. Data from the Social Security 
Administration reveal that severe disability resulting from 
work-related injury was almost twice as high among Hispanics as among 
nonminority workers in 1980. It may be presumed that the impact of 
occupational injury on Hispanics may be much higher because of the 
number of migrants and undocumented workers who are not reported when 
injured and who do not receive workmen s compensation benefits. 

In 1982, Hispanics were classified in the employment category of 
operators" almost twice as often as nonminorities (23 percent versus 
12 percent) . Hispanics have lower rates of employment than 
nonminorities as professional workers (9 percent versus 17 percent) 
and in management positions (7 percent versus 17 percent). They have 
higher employment rates as general laborers (7 percent versus 4 
percent) and as farm laborers (4 percent versus 1 percent) . 



54 



Hispanic Americans have a very strong family and community 
orientation. The church and parish community are an important focus 
of family and social life for many Hispanics . In more rural settings, 
some Hispanics view the community as an extension of the family and 
feel that it has a protective and healing force that may be used to 
reinforce an individual's own coping skills. However, regional 
studies on naturalistic support systems indicate that the quality of 
support, rather than the number of sources, has a greater impact on 
the effectiveness of support systems in ameliorating stress. Little 
research has been done to explore how family, church, and community 
interact to provide support to a community member. Many Hispanics 
accord their elders respect and authority and value their support in 
times of distress. 

Social Characteristics of Asian/Pacific Islanders 

The number of Asian/Pacific Islanders in the United States grew 
by 120 percent between 1970 and 1980. As of 1980, this group numbered 
3.7 million and constituted 1.6 percent of the population. 
Asian/Pacific Islanders have a far larger percentage of foreign-born 
persons (58 percent) than any of the other United States minority 
groups . 

Asian/Pacific Islanders come from more than 20 different 
countries. The three most common countries of origin are China 
(812,000 persons), the Philippines (781,000), and Japan (716,000). 
A distinct trend in Asian/Pacific Islander demographics of the past 
decade has been the immigration of large numbers of Southeast Asians 
under the Refugee Resettlement Program. However, data on social 
charactistics of Asian/Pacific Islanders principally reflect 
information from the three largest subgroups. 

Asian/Pacific Islanders live predominantly in the western part of 
the United States, although their concentration in this region has 
begun to decrease noticeably. Fifty-six percent now live in the West, 
compared with 70 percent at the time of the 1970 census. Four out of 
every five of the country's recent Indochinese immigrants live in 16 
states; one-third of the total live, in California, and one-tenth are 
in Texas . 

The median age of the Asian/Pacific Islander population is 28.7 
years . This is higher than that of the other three largest minority 
groups but still lower than the median age (31.3 years) of the 
nonminority group. The age-adjusted mortality rate is 3.2 deaths per 
1,000 population. Only 11 percent of Asian/Pacific Islander 
households are headed by women; this is less than the nonminority 
rate. Fifty-eight percent of Asian/Pacific Islander women are in the 
workforce. 



55 



The median educational level of Asian/Pacific Islanders is quite 
similar to that of the general population. Three out of four have 
completed high school, and approximately one out of three holds a 
college degree. 

The median income level for Asian/Pacific Islander families, as 
shown in the 1980 census, was $22,713. Median income among 
Asian/Pacific Islander families is consistently higher than that of 
any other group, including the nonminority group. Asian adults, 
however, often share a household for reasons of exigency, thereby 
inflating the reported "family" income. As a result, the true extent 
of poverty among Asian/Pacific Islanders is often masked. 

Moreover, income differs substantially among the Asian subgroups: 
it is highest among those from Japan and lowest by far ($12,840) among 
the Vietnamese. The unemployment rate shows similar variations. In 
1979, the overall poverty rate for Asian/Pacific Islanders was 13.1 
percent; the range was from 7 percent for the Japanese and Filipino 
subgroups to more than 35 percent for the Vietnamese. The 
unemployment rate for the overall Asian/Pacific Islander population 
stands at 4.7 percent, which is nearly two percentage points lower 
than the nonminority rate. 

The primary source of calories for many Asian/Pacific Islanders 
is rice. The varieties of rice used and the techniques of 
preparation, however, are diverse. Prewashed or unenriched rice poses 
risks of low vitamin B and mineral intake, although such deficiencies 
may be overcome by adequate intake of pork or fish. Consumption of 
vegetables, fruits, fish, and shellfish is relatively higher; but 
intake of animal protein is relatively lower than that of the 
nonminority population. Dairy products are used much less frequently; 
however, the traditional sources of calcium in the Asian diet are from 
soy bean curd, sardines, or green leafy vegetables. With 
acculturation, adaptation of the traditional Asian diet to the foods 
most readily available in the United States generally involves 
increasing the proportion of caloric intake coming from animal 
protein, fats, and refined sugar. Intakes of complex carbohydrates 
and cholesterol increase, while fiber intake decreases. Such changes 
are reflected in the higher weight and increased rate of coronary 
disease among Asians in the United States compared with cohorts in 
their countries of origin. Many foods in the Asian diet, such as 
salted and pickled vegetables, soy sauce, meat and fish pastes, and 
fermented soy bean curd, are high in sodium. 

When all aspects of the Asian/Pacific Islander diet are taken 
into consideration, an area of concern is possible growth stunting, 
which may affect as many as one-third of the children between two and 
five years of age. However, the data are insufficient to determine if 
this is true and if it has health consequences for Asians/Pacific 
Islanders. Low weight for height is not a problem. Obesity, a 
notable health risk among other minority groups, is not common among 
Asian/Pacific Islanders. 



56 



Information on occupational patterns and employment rates of 
Asian/Pacific Islanders are most complete for the larger subgroups, 
Chinese, Japanese and Filipinos. Although there are relatively larger 
numbers of Asian/Pacific Islanders employed in white collar positions, 
a disproportionate number of Asian/Pacific Islanders are engaged in 
jobs that are substantially below their educational levels. Taking 
into account both men and women, 19 percent of Chinese, 15 percent of 
Japanese, and 14 percent of Filipinos have professional occupations, 
compared with 13 percent for nonminorities . At the same time, 19 
percent of Chinese, 17 percent of Filipinos, and 13 percent of 
Japanese workers have service occupations, compared with only 11 
percent of nonminorities. 

Recently arrived Indochinese refugees constitute a specific 
subset within the larger Asian population that may vary considerably 
from the demographic patterns cuurently reported for more established 
Asian groups. Their unemployment rate and poverty rate are much 
higher than other Asian groups, and nonminorities. Furthermore, 
because many of these newcomers speak little or no English, they often 
are forced to seek employment in positions with a disproportionate 
number of occupational hazards or in low-level service areas. 

Many Asian/Pacific Islanders pride themselves on their 
independence and self-sufficiency. Consequently, some are 
particularly reluctant to seek health services, especially for mental 
illness or for counseling. In some Asian countries, the ability to 
control the expression of feelings is often felt to be a sign of 
refinement. The family is very important to many Asians, and some 
Asians believe that seeking help outside the family is a sign of 
weakness. Although cultural patterns of family reliance often 
strengthen an individual's social support resources, they also may 
pose a barrier to care when it is truly needed. Some Asian/ 
Pacific Islanders consult traditional healers such as acupuncturists 
and herbalists or use traditional remedies as supplements to other 
western medical care sources. The extent of use and efficacy of 
traditional medicine among Asian/Pacific Islanders is unknown. 

Social Characteristics of Native Americans 

Native Americans include American Indians, Aleuts, Alaska 
Eskimos, and Native Hawaiians. Data reported here, however, refer 
primarily to American Indians for whom information is most available. 

American Indians are the smallest minority group in the United 
States. In 1980, they numbered approximately 1.5 million, less than 
one percent of the total population. The average American Indian 
family has 4.6 members; this is larger than any other minority or 
nonminority group. The birth rate among American Indians is nearly 
twice that of other groups, and the average life expectancy is six 



57 



years less. The median age of American Indians --22 .4 years--is lower 
than that of any other group. It is nearly nine years lower than that 
of the nonminority population. 

Nearly one out of every four American Indian households is headed 
by a woman, and approximately half (48 percent) of American Indian 
women are employed outside the home. 

The overall educational attainment of American Indians is the 
lowest of all minority groups. The 1980 census revealed that fewer 
than one out of three (31 percent) have graduated from high school and 
that only 7 percent hold college degrees. 

Likewise, median family income is well below the national level. 
In 1979, it was $15,900 per year, which is $7,200 below the level for 
the nonminority group. Twenty-nine percent of American Indian 
families lived in poverty in 1979; this is similar to the overall 
poverty rate among Black and Hispanic minorities but substantially 
higher than the poverty level of Asian/Pacific Islanders and of the 
nonminority group. The unemployment rate among American Indians in 
the civilian labor force in 1979 was more than 13 percent. 

One-half of all American Indians live in the western or 
southwestern United States. Twenty-four percent live on 
reservations, and another 8 percent live on historic trust areas in 
Oklahoma. Most of these reservations have fewer than 1,000 residents; 
only one reservation has a population greater than 100,000. 

Tribal variations are considerable in current diets of American 
Indians. Factors contributing to dietary differences are food 
availability, preference for nonminority food, and place of residence 
(i.e., urban or reservation). In general, the diets of many 
traditional American Indians today are high in refined carbohydrates, 
fat, and sodium. They are low in meat, eggs, cheese, and milk; this 
may indicate a potential problem with protein deficiency. 

A relatively high percentage of American Indian women report that 
they breast feed their infants, and the growth patterns indicating 
adequate childhood nutition are not markedly different from that of 
nonminority children. There is, however, a disproportionate incidence 
of high weight for height among American Indian children that begins 
in early childhood. Likewise, obesity is a problem for a large 
proportion of American Indian adults and may be associated with the 
high risk of diabetes mellitus in this population. Alcohol-related 
disease is also a source of concern among the American Indian 
population, and excessive alcohol consumption may interfere with 
adequate nutritional intake. 

Native Americans, along with Blacks, have the highest rates of 
injury and death from nondisease causes. Motor vehicles are included 
in nearly half of all accidental injuries, and the rate of such accidents 
among Native Americans is higher than that of any group. 



58 



The unemployment status of a large number of American Indians 
seems due to a combination of socioeconomic and cultural factors. 
However, industrial firms attracted by tax incentives, low labor 
costs, and an accessible labor force have begun moving onto some of 
the Indian reservations. Although they provide a much needed source 
of employment, many of these industries are of the type that produce a 
number of occupational risks. This may increase the health risks to 
American Indian workers. Because of traditional cultural beliefs, some 
Native Americans are reluctant to use prescribed safety measures or 
precautions. The National American Indian Safety Council (NAISC), 
representing a cross-section of the Indian tribes, is working to 
establish guidelines that may assist in reducing occupational hazards 
for these workers . 

The mores and cultural patterns of the nonminority population 
imposed upon Native Americans have disrupted their traditional way of 
life. A sense of powerlessness and hopelessness has often been 
observed as a result and may be related to the high incidence of 
alcohol abuse, suicide, depression, and obesity among this population. 

The medical and socioeconomic consequences of alcoholism, which 
is sometimes viewed as a way of coping with cultural disruption, are 
extensive and tragic; they include death and injury from motor vehicle 
accidents, assaults, family violence and disintegration, and 
alcohol-related disease. Alcoholism also contributes to instability 
of the work force. 

American Indians, however, are also observed to draw upon 
traditional sources of strength to cope with stressors. Traditional 
strengths include the family, the tribe, and the land itself. Yet, 
many American Indian children leave their homes today, most often to 
go to boarding schools. Many of those who have studied the problems 
of the American Indian family believe that this practice has weakened, 
rather than strengthened, family stability. 

It is recognized that traditional medicine men play powerful 
roles in the health practices of this population. Health care and 
social programs should be coordinated with these individuals, with the 
awareness that treatment outcome is strongly influenced by the belief 
system of the patient. 



59 



REFERENCES 

1. Bureau of the Census. (1983). America's black population, 

1970 to 1982: A statistical view . Washington, DC: 
U.S. Department of Commerce. 

2. Bureau of the Census. (1980). American Indian areas and 

Alaska Native villages: 1980 census of the population . 
(Supplementary report). Washington, DC: U.S. Department 
of Commerce. 

3. Bureau of the Census. (1984, January 8). American Indian, 

Eskimo, and, Aleut populations . Washington, DC: U.S. 
Department of Commerce. 

4. Bureau of the Census. (1984, July). Asian and Pacific 

Islander population . Washington, DC: U.S. Department of 
Commerce. 

5. Bureau of the Census. (1984, January 8). Asian and Pacific 

Islander population . Washington, DC: U.S. Department of 
Commerce. 

6. Bureau of the Census. (1980). Asian and Pacific Islander 

population by state: 1980 (Supplementary report) . 
Washington, DC: U.S. Department of Commerce. 

7 . Report of the Working Group on Health Education among Minorities . 

Unpublished manuscript, Task Force on Black and Minority Health, 
DHHS. 

8. Bureau of the Census. (1983, May). General population 

characteristics: 1980 census of the population (Chap. B, 
Vol. 1, Pt. 1). Washington, DC: U.S. Department of 
Commerce. 

9. Haan, M. N. , & Kaplan, G. A. (1985). Socioeconomic position 

and minority health . Unpublished manuscript. Task Force on 
Black and Minority Health, DHHS. 

10. [Demographic profile of the U.S. Asian/Pacific Islander population] 

(1985). Unpublished raw data. Task Force on Black and Minority 
Health, DHHS. 



60 



11. Keefe, S. E., Podilla, A. M. , &. Carlos, M. L. (1978). Emotional 

support systems in two cultures: A comparison of Mexican 
Americans and Anglo Americans . Los Angeles, CA: 
UCLA Spanish-Speaking Mental Health Research Center. 

12. Kumanyika, S. K. , & Helitzer, D. L. (1985, February). 

Nutritional status and dietary patterns of racial 
minorities in the United States . Unpublished manuscript, 
Task Force on Black and Minority Health, DHHS . 



13. National Institute for Occupational Safety and Health. 

(1981, July). Issues affecting minority workers. 
Proceedings of the National Conference on Occupational 
Health and Safety . U.S. Department of Health, Public 
Health Service, Centers for Disease Control. Cincinnati, OH. 

14. Parron, Delores. (1985). Stress and Coping . Unpublished 

manuscript. Task Force on Black and Minority Health, DHHS. 

15. Subcommittee on Cancer in Minorities. (1985). [Demography and 

health services' patterns]. Unpublished raw data, Task Force 
on Black and Minority Health, DHHS. 

16. Yu, E., Chang, C. F., Liu, W. T. , & Kan, S. H. (1984). Asian-White 

mortality differences: Are there excess deaths ? 
Unpublished manuscript. Task Force on Black and Minority 
Health, DHHS. 



61 



MORTALITY AND MORBIDITY INDICATORS 



Introduction 

Differences in life expectancy between minorities and 
nonminorities strongly suggest the existence of health problems among 
certain segments of the population. Although life expectancy 
dramatically summarizes the overall differences in specific causes of 
death and illness among various groups in the United States, Secretary 
Heckler asked the Task Force to go beyond life expectancy data and 
investigate more fully the magnitude of the disparity in health status 
of minority groups compared with nonminorities, and its causes. 
Consequently, the Task Force examined and identified appropriate 
indices to measure the various disparities, identified the leading 
causes of death and their ramifications within each minority, examined 
other indicators of health status and morbidity for minority groups, 
and reviewed the socioeconomic correlates of these factors. Based on 
this investigation, the Task Force was to suggest approaches for 
reducing the identified disparities. 

Measures of Mortality 

In addition to life expectancy, two other indices were used by 
the Task Force to summarize mortality differentials: 1) excess 
deaths, and 2) relative risk of death. 

"excess deaths" expresses the difference between the number of 
deaths actually observed in a minority group and the number of deaths 
that would have occurred in that group if it experienced the same 
death rates for each age and sex as the White population (1). "Excess 
deaths" are sometimes referred to as "observed minus expected deaths 
(when expected deaths are based on the death rate of the White 
population) . Excess deaths can be calculated for each age and sex 
group as well as for specific causes of death. When minority death 
rates are higher than those of Whites, excess deaths will be a 
positive number greater than zero; it will be zero when the rates are 
the same as for Whites; and it will be a negative number when the 
death rates for minorities are lower than for Whites . 

The measure of excess deaths depends on differences in death 
rates between the minority and nonminority populations and specifies 
the actual deaths in a minority group attributable to these mortality 
rate differences . The number of observed excess deaths also depends 
on the size of the minority population and the number of total deaths. 
Further analysis with this measure can identify excess deaths due to a 
specific cause such as heart disease, affecting the greatest number of 
people in a particular group. 



63 



To account for the differences in size of the population, the 
"relative risk" of death is used. "RELATIVE RISK" is the ratio of the 
minority death rate to the White death rate. Relative risk also can 
be calculated for specific causes of death and for each age and 
sex group. When the relative risk of death is greater than 1.0, it 
indicates that the death rate is proportionally higher in the minority 
group than in Whites; a value of 1.0 or less than 1.0 indicates that 
the minority group has the same or lower death rate as Whites . A high 
relative risk for a specific cause of death may be misleading if a 
disease is rare and affects a small number of people. The relative 
risk for a rare condition may appear to indicate a disproportionally 
high risk for a problem that may not be serious in terms of excess 
deaths because so few individuals are affected. 

The Task Force used excess death as the primary indicator of the 
disparity and used measures of relative risk to confirm and extend 
findings of the excess deaths' index. Both excess deaths and 
relative risk as applied by the Task Force are statistics which 
present death rates for minority groups only as compared to the White 
population. 

The age-adjusted death rate for the United States, which takes 
into account the age structure of different population groups, was 
553.8 deaths per 100,000 population, and is estimated to be 549.6 for 
1983 (2) . Figure 1 shows the average annual age-adjusted death rate 
for several racial groups. Life expectancy at birth has been rising, 
increasing from 74.6 years in 1982, to 74.7 years in 1983. 

Despite these encouraging overall trends, differences in health 
status indicators remain between minority groups and Whites, as seen 
in Figure 2. Life expectancy at birth for White males in 1982 was 71.5 
years; for Black males, it was 64.9 years. Since life expectancy is 
not routinely available for other minority groups, special 
calculations were commissioned by the Task Force. These data indicate 
that life expectancy for Native American males was 70.4 years in 
1979-81, and life expectancy for Asian males was about seven years 
greater than that of Whites. Data on Hispanics are not available to 
estimate comparable life expectancy. Minority and nonminority women 
have a longer life expectancy than men; minority women, however, 
experience similar disparities in health status compared to 
nonminority women. Asian females have the highest life expectancy of 
any group (3) . 

The Task Force explored the disparity in death rates between 
minorities and Whites by disease category, by analyses of relative risk 
of death for the different disease categories (shown for Blacks in 
Table 5) and by analyses of excess deaths. Based on these analyses, 
the Task Force observed that four of every five excess deaths among 
minorities result from six causes: cancer, heart disease and stroke, 
infant mortality, diabetes, homicide and unintentional injuries, and 
chemical dependency (primarily alcohol abuse as revealed by 



64 



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Table 5 



Age-Adjusted Death Rates by Selected Cause, Race, and Sex 
United States, 1980 
(Rate per 100,000 Fbpulation) 



Black White Relative Black White Relative 

Male Male Risk Female Female Risk 



Total Deaths 
(All Causes) 



1,112.8 



745.3 1.5 



631.1 411.1 



1.5 



Heart Disease 



327.3 



277.5 



1.2 



201.1 



134.6 



1.5 



Stroke 



77.5 



41.9 1.9 



61.7 



35.2 



1.8 



Cancer 



229.9 



160.5 1.4 



129.7 107.7 



1.2 



Infant Mortality 



2,586.7 1,230.3 2.1 



2,123.7 962.5 



2.2 



Homicide 



71.9 



10.9 6.6 



13.7 



3.2 



4.3 



Accidents 



82.0 



62.3 



1.3 



25.1 



21.4 



1.2 



Cirrhosis 



30.6 



15.7 



2.0 



14.4 



7.0 



2.1 



Diabetes 



17.7 



9.5 1.9 



22.1 



8.7 



2.5 



SOURCE: NCHS, Health: United States, 1983, Tables 9 and 15. 



67 



cirrhosis). Figure 3 illustrates the major contributors to excess 
death for Blacks, in 1980, for those who died before age 45 or before 
age 70. The data clearly depict that the bulk of excess deaths in 
each age bracket are attributable to the six causes cited. Homicide 
and accidents, infant mortality, and heart disease and stroke 
contribute the greatest number of excess deaths before age 45 in 
Blacks. Heart disease and stroke, and cancer increasingly contribute 
to excess deaths in Blacks when deaths up to age 70 are examined. The 
same six causes of excess death also apply to Hispanics , Asian/Pacific 
Islanders, and Native Americans, although the ranking may vary. 

Subcommittees were formed to investigate the reasons for 
disparities due to these six causes of death. Suicide among 
minorities was added to the charge to the Subcommittee on Homicide and 
Unintentional Injuries based on the contribution of suicide to the 
excess deaths of Native Americans. Detailed results are found in the 
Subcommittee summary reports and in later volumes of this Task Force 
report. 

Other Health Status Measures 

Morbidity and health status measures were also examined as 
indicators of the disparities in health between nonminorities and 
minorities in the United States. These measures were taken largely 
from the NCHS National Health Interview Survey (NHIS), an annual 
survey sampling 40,000 households nationally. Morbidity estimates are 
based on prevalence rates from self-reports of the sample population 
for a selected list of diseases. Health status measures include 
self -assessed health, number of physician and dentist visits, and 
number of hospital admissions. An analysis also was commissioned to 
determine differences in ambulatory care use among minorities (4) . 

The 1976 Survey of Income and Education (SIE) provided measures of 
social characteristics related to self-assessed health status for 
minorities. Additional information from the Health Care Financing 
Administration End-Stage Renal Disease Program and from the DHHS 
Office for Civil Rights reports of hospital admissions and emergency 
room visits was examined. These sources proved to be severely limited 
for the needs of the Task Force because of difficulty in identifying 
minorities by age-sex group and health problem for comparison to 
Whites . 

Limitations of Data 

A variety of measures of health status are needed to draw 
conclusions about diferences in health status among minority 
populations; single measures such as national mortality summaries may 
not provide a complete enough picture. Although mortality data are 
available by age, sex, and race for Blacks, Asian/Pacific Islanders, 
Native Americans, and Whites, the Task Force noted that one of the 
most serious data deficiencies is the lack of national mortality data 



68 



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for Hispanics . These data are usually obtained from death 
certificates but, for Hispanics, ethnicity is not uniformly recorded 
in every State. 

In addition, mortality data are usually not recorded for 
subgroups within Asian/Pacific Islander and Native American 
populations. Although mortality rates are believed to vary among 
subpopulations , no information is available on a national basis from 
which to analyze data for subgroups. 

The Task Force also noted that the sample sizes of minorities, 
other than Blacks, in surveys tend to be insufficient to obtain an 
accurate picture of disparities in health compared to Whites . Data on 
the health status of Native Americans and Asian/Pacific Islanders 
compiled from surveys must be aggregated over time to obtain adequate 
numbers to draw statistically valid conclusions. Despite these 
limitations, the National Health Interview Survey (NHIS) does provide 
sample coverage of Native Americans and Asian/Pacific Islanders. 
Health information about American Indians and Alaska Natives on or 
near reservations is available from the Indian Health Service. 

As in the mortality data, the NCHS health survey statistics on 
illness and disability do not generally distinguish subgroups within 
the racial/ethnic groups as a whole. For example, recent immigrants 
from Southeast Asia have more health problems than the more 
established Asian/Pacific Islander groups, such as Chinese, Japanese, 
and Filipinos, yet all data are aggregated into the Asian/Pacific 
Islander minority group which, overall, has a greater life expectancy 
than the White population (5). 

The following sections present highlights of the mortality and 
morbidity findings for Blacks, Hispanics, Asian/Pacific Islanders, and 
Native Americans. 

MINORITY HEALTH INDICATORS 

Blacks 

Of two million American deaths per year, roughly twelve percent 
are Black. Between 1979 and 1981, an average of 227,000 Blacks died 
each year. Of these, 139,000 Blacks were under the age of 70 years. 
About 59,000 of these deaths among Blacks under age 70 would not have 
occurred had Blacks experienced the same age-sex death rates as 
Whites. These "excess deaths" represent 42.3 percent of all Blacks 
who died before the age of 70. Table 6, based on death certificate 
information, indicates the major causes of the excess deaths in Blacks 
under ages 45 and 70; Figures 4 and 5 illustrate the contributors to 
the average annual excess deaths for Black men and women. 

The disparity between the death rates of Blacks and Whites 
(excess deaths) affects certain age groups more than others. Compared 
to Whites, Blacks have twice the rate of infant mortality. The 



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disparity is smaller through age 24, followed by a sharp rise in 
excess deaths thereafter through age 64. Thus, for infants and adults 
through middle age, the excess deaths are most pronounced. 

In later life, minorities have lower death rates for many 
diseases than do nonminorities . This "survivor effect", or mortality 
crossover, has been attributed to hardiness among survivors in a 
population that has a higher early-age death rate. 

The excess death rates for Black males and females are similar across 
age categories except that a greater percentage of males than females 
died between the ages 25 to 44, but a greater percentage of females 
than males died between the ages of 45 to 69. 

Homicide was the major cause of these excess deaths occurring in 
Blacks, aged 25 to 44 years. Homicide accounted for 38 percent of the 
male excess deaths and 14 percent of the female excess deaths below 
age 45. Excess Black deaths between the ages of 45 to 69 were due 
mainly to cancer, heart disease, stroke, diabetes, and cirrhosis. 

As seen in Figure 4, homicide and unintentional injuries are the 
major contributors to excess deaths for Black males. Heart disease 
and stroke and cancer assume greater importance with advanced age. 
For Black females, as shown in Figure 5, death from heart disease and 
stroke assume the same importance as homicide and unintentional 
injuries do for younger Black males. Diabetes is increasingly 
important in the excess deaths of older Black females. Though 
diabetes itself accounts for less than 2 percent of male excess deaths 
and 5 percent of female excess deaths (to age 70), it is a major risk 
factor for heart disease and leads to other serious consequences, 
including amputation and blindness, if uncontrolled. 

Hypertension similarly has serious health consequences if left 
untreated. It is the leading cause of kidney failure and 
hypertension-related end-stage renal disease in Blacks and is a major 
concomitant of heart disease and stroke. Hypertension itself accounts 
for more than 5 percent of the excess deaths in Blacks. Cirrhosis 
accounts for more than 3 percent of excess deaths in both Black males 
and females (to age 70), and unintentional injuries account for 6 
percent of the excess in males and 2 percent of the excess in Black 
females (to age 70). to age 70. Many of the causes of excess deaths 
in Blacks are amenable to reduction through preventive and public 
health activities. Hypertension and diabetes, which relate to other 
conditions, are controllable through proper treatment. 

Relative risks for specific causes of death under age 45 are 
disturbingly high among Blacks compared to the White population, and 
further support the findings of excess death. Blacks under 45 years 
of age have a relative risk of death from all causes nearly twice that 
of Whites (1.96 for males and 1.93 for females). Relative risk does 
not indicate the largest numbers of deaths; rather, it reflects the 



74 



comparative likelihood of dying from a particular cause. The 
conditions for which relative risks of death are highest for Black 
(compared to White) males and females under age 45 are: 

Males Females 



Tuberculosis 


17 


4 


15 


6 


Hypertension 


10 


2 


13 


4 


Homicide 


6 


6 


4 


3 


Anemias 


6 





5 


2 



Deaths from tuberculosis (TB) and anemias, although not major causes of 
death, occur at a higher frequency among Blacks and may be related to 
socioeconomic conditions commonly associated with these diseases. 

Morbidity data from NHIS substantiate the problems Blacks, 
especially women, face with hypertension, diabetes, and anemia. Black 
women ages 45-64 had a prevalence rate of hypertension 85 percent 
higher than White women, with hypertension afflicting 43 percent of 
the Black women sampled in the 1979-81 NHIS. More striking data also 
appear. Black women ages 25-44 had a prevalence rate for hypertension 
2.6 times greater than White women of the same age; diabetes rates in 
Black women 45-64 were 2.7 times higher than those in Whites, and 
anemia rates reported were higher at all ages, ranging from 6.7 times 
in children ages 1-14 to 2.6 times higher in Black women 15-44. These 
morbidity figures clearly show the health disparities in Blacks 
surfacing early in life, and several health conditions responsible for 
the disparities are known risk factors for cardiovascular disease. 

Disability data from the 1976 SIE provides additional information 
on health differences in Blacks. Blacks reported lower rates of 
disabling heart disease than Whites at each income level. However, 
because the rates decrease as income rises and there are proportion- 
ally more Blacks among the lower income strata, the overall Black 
rates of disabling heart disease are higher. Similar correlations can 
be found between education and other diseases reported in SIE. The 
main conclusion from this analysis is that income and education are 
major factors influencing health status. Lack of income and education 
must be recognized as risk factors for disease and death in Blacks. 

Hispanics 

Hispanics are the second largest minority group in the United States. 
For many data collection purposes (e.g., birth and death certification), 
Hispanics are classified as an ethnic rather than a racial minority and are 
often noted in vital statistics' information as White. 

The primary sources of mortality data for all racial groups are 
death certificates recorded by the states and used by Federal agencies 
such as NCHS in computing national mortality statistics. Because 
uniform procedures for reporting Hispanic ethnicity have not been 
adopted nationwide, such information is not captured on many documents 
including death certificates. 



75 



One effect of the lack of uniformity in noting Hispanic ethnicity 
is that national mortality statistics for Hispanics cannot be compiled 
from existing data and are therefore not available. Many states with 
large Hispanic populations, such as Florida and New Jersey, have no 
mortality data on Hispanics because ethnicity information is not 
required on death certificates. 

To compensate for the lack of national data, the Task Force 
undertook a series of activities to obtain Hispanic mortality and 
morbidity information. The Task Force established a panel of Hispanic 
advisors, brought in Hispanic experts to speak to and consult with the 
Task Force, participated in COSSMHO and other national meetings of 
Hispanic health professionals, and commissioned special studies where 
data were available. For example, Spanish-surname data from Texas and 
national data on death certificates listing either Mexico or Cuba as 
the country of birth were used to generate information on the health 
problems of Hispanics compared to non-Hispanic Whites . This 
information provided the best indication of Hispanic health problems 
available to the Task Force until national data on Hispanic mortality 
can be collected and analyzed. 

Excess deaths were calculated for three Hispanic populations: 
the Texas Spanish-surname, the Cuban-born, and the Mexican-born 
populations. Excess deaths were fewer than those found for Blacks in 
the 1979 to 1981 period. In the Spanish-surname population of Texas, 
14 percent of all deaths were excess deaths when compared to the White 
non-Spanish-surname population of the State (6). Among persons of 
Cuban birth who died in the U.S. between 1979 and 1981, excess deaths 
amounted to 2.2 percent of all deaths; for the Mexican-born 
population, excess deaths amounted to 7.2 percent of all deaths. 

The causes of excess deaths among the three Hispanic groups 
analyzed are similar. As seen in Table 7, homicide was the leading 
contributor to the disparity among both Cuban-born and Mexican-born 
Hispanics. No other major cause examined contributed to the excess 
deaths in the Cuban-born. Unintentional injuries, heart disease and 
stroke, cirrhosis, and diabetes appeared to be major causes of the 
disparity in the Mexican-born. Among the Spanish-surname population 
of Texas, external causes, especially motor vehicle accidents and 
homicide, were the primary contributors to excess death. Some 
differences among the three Hispanic groups may reflect the 
limitations in the data bases used in the separate analyses. For 
example, infant mortality is virtually eliminated when the analyses 
are limited only to the foreign-born. 

These data for selected Hispanic populations suggest that the 
relative risks for deaths from the causes evaluated are generally 
lower than those of Blacks. Yet, certain causes of mortality before 
age 45 merit special attention. The most important of these is 
homicide among both Cuban-born and Mexican-born Americans, an excess 
also noted in the Spanish-surname data. The relative risk of death 
from homicide is 6.4 in Cuban-born and 5.9 in Mexican-born males under 



76 



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77 



age 45 compared to the overall White male population under 45. For 
females, the comparable figures using the overall White female 
populations as a base are 2.4 and 1.5, respectively, suggesting that 
homicide is not solely a problem for young Hispanic males. 

Deaths from unintentional injuries pose a risk to males who are 
Mexican-born under age 45, but not for the Cuban-born. The relative 
risk of death due to unintentional injuries for Mexican-born males 
under age 45 is 1.7; for females it is 1.0 (the same as White 
females). This result is explained to some extent by examining the 
relative risk of death due to cirrhosis. Mexican-born males have a 40 
percent higher risk of death from cirrhosis than the White population 
(i.e., a relative risk of 1.4). Cirrhosis is associated with 
alcohol abuse and suggests that alcohol abuse in Mexican-born males 
may be a problem. Alcohol abuse is also suggested to play a role in 
higher risk of death due to accidents. Again, analysis of 
Spanish-surname data confirm that there are excess deaths from 
unintentional motor vehicle injuries. 

Tuberculosis carries the largest relative risk of death 
under age 45 to the Mexican-born, 7.8 for males and 11.0 for females, 
as well as being high in Cuban-born males, 8.0. For the major killers 
(heart disease, stroke, and cancer), the risks of death for the 
Hispanic groups are less than that of non-Hispanic Whites. Overall, 
the risk of death under age 45 is 1.4 times greater in Mexican-born 
males and 1.2 times greater in Cuban-born males than Whites; however, 
risk of death for foreign-born Hispanic females is less than that for 
females under age 45 in the general, nonminority population. 

Morbidity rates and health status measures for Hispanics were 
analyzed to investigate possible reasons for the health differences 
revealed by the mortality data, as was done with Blacks. Trevino and 
Moss (7) examined a number of health status indicators from the NHIS, 
including physician and dental visits, hospital stays, disability 
days, acute conditions, and activity limitations due to chronic 
conditions, for Hispanics, Blacks, and non-Hispanic Whites in the 
period 1978 to 1980. The size of the Hispanic sample in NHIS, 
however, is too small to generalize to the Hispanic population when 
age, sex, Hispanic origin (Cuban, Mexican, and Puerto Rican) and 
health condition are taken into account, as must be done to get 
results meaningful to the charge of the Task Force. 

The only statistically significant results reported in the 
analysis of the NHIS data are prevalence rates of digestive conditions 
among Puerto Rican females ages 25-44, which are 2.2 times greater 
than those in non-Hispanic Whites. Skin and musculoskeletal 
conditions among Cuban females are twice as high as those among White 
non-Hispanics . Other results suggest that Hispanics in the NHIS 
sample suffer from a number of conditions with potentially serious 
outcomes if left untreated, but the small sample sizes preclude 



78 



generalization to the entire Hispanic population group. A better 
picture of the health of Hispanic Americans should be available when 
analyses of the Hispanic Health and Nutrition Examination 
Survey (HHANES) are published. 

Native Americans 

Table 8 shows a striking pattern of excess deaths, by age groups, 
among American Indians. The excess death rate of Indians under age 45 
is high, at 43 percent. Of all American Indians who die before age 
70, 54 percent die before age 45. Excess deaths before age 70 amount 
to one of every four deaths in American Indians. Eighty-seven percent 
of the excess deaths in American Indians occur before the age of 45. 
(The comparable figure for Blacks is 39 percent.) 

Eighty percent of excess deaths occurring before age 45 and 99 
percent of the excess deaths up to age 70 are due to six causes. 
These six causes, in order of greatest contribution, are: 
unintentional injuries, cirrhosis, homicide, suicide, pneumonia, and 
diabetes. Conspicuously absent are heart disease and cancer which 
have higher overall rates in the White population and which are 
considered diseases of middle and later life. 

Deaths from unintentional injuries account for 48 percent of 
excess deaths for males and 40 percent of the excess deaths for 
females (up to age 45). Cirrhosis accounts for 11 percent of the male 
excess and 20 percent of the female excess deaths prior to age 45. 
Homicide accounts for 9 percent and 8 percent of the excess among 
American Indian males and females under age 45, respectively. From 
these causes, it would appear that alcohol abuse is one of the most 
serious contributors to premature deaths among young adult American 
Indians . 

The risk of death for American Indians under age 45 is 1.8 times 
that of Whites for both sexes. Over age 45, relative risk of death 
for Native Americans is equal to or slightly lower than for Whites. 
The lower relative risk observed over age 45 might be due to a 
"survivor effect" similar to that among older Blacks. Causes with 
higher relative risks are seen in Table 9. 

The extremely high relative risks of death for females due to 
cirrhosis and tuberculosis in part reflect the low rates for 
White females who are the basis of the comparison. Nonetheless, these 
relative risks do convey the dimensions of the problem in this 
population. These statistics further confirm the magnitude of alcohol 
abuse among young American Indians of both sexes. The high risks of 
TB , combined with relative risks of death above 1.0 for anemia and 
hepatitis, probably reflect socioeconomic correlates of these diseases. 



79 



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80 



Table 9 

Relative Risk of Death for American Indians by Cause* 

Cause Relative Risk 



Male Female 



Cirrhosis 6.1 11.1 

Tuberculosis 8.5 9.8 

Chronic Renal Disease 2.7 4.7 

Unintentional Injuries 2.1 2.4 

Drowning 2.8 2.4 

Homicide 2.2 2.6 

Diabetes 2.2 1.1 

SOURCE: Duke University analysis commissioned for the Task Force, 1984. 
*NCHS microdata mortality tapes and 1980 U.S. Census population at risk. 



Too few Native Americans are sampled in the NHIS to derive 
population-level prevalence estimates for selected diseases and 
disability. The responses reported by the sample respondents tend to 
reflect the mortality results, but it would be misleading to attempt 
to extrapolate these to represent morbidity in Native Americans. The 
Indian Health Service (IHS) provides statistics about the population 
it serves, but these data are obtained from only 60 percent of the 
total American Indian and Alaska Native population. The data that 
are available, however, along with selected examples such as the high 
rate of diabetes among Pima Indians, indicate the existence of serious 
health problems. More reliable information on the Native American 
population is needed. Clearly, more needs to be known about 
environmental and psychosocial contributors to the widespread abuse of 
alcohol by young Native Americans if the premature loss of life in 
this minority population is to be prevented. 

Asian/Pacific Islanders 

The Asian/Pacific Island minority, in aggregate, is healthier 
than all racial/ethnic groups in the United States, including Whites. 
There are virtually no excess deaths, as seen in Table 10, when all 
Asian ethnic groups are combined, and Asians have a greater life 
expectancy than Whites. Yet, specific health problems do exist among 
various subgroups of this population. The Task Force explored several 
avenues to determine those health disparities that might be masked as 
a consequence of combining the subpopulations . The Task Force 
established an Asian advisory panel, commissioned papers from experts 
in the field, and visited the Chinese Hospital in San Francisco and 
consulted with the School of Public Health at the University of Hawaii. 



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82 



The University of Hawaii is conducting a major study of the 
health status of Americans in the Pacific. Preliminary results 
indicate that, compared to Caucasians in Hawaii, Native Hawaiians 
experience excess deaths for heart disease, cancer, diabetes, infant 
mortality, and accidents. Cancers of the stomach and lung are 
particularly high relative to Whites. Excess deaths due to accidents 
are believed to result from the riskier occupations of Native 
Hawaiians, relative to Whites. 

The primary morbidity problems found in Native Hawaiians include 
heart conditions, hypertension, diabetes, asthma, gout, and back 
problems - results in keeping with the mortality findings. The 
University of Hawaii study also applied "excess deaths" methodology to 
the Pacific Island territories, but the vital statistics in those 
territories were inadequate to report findings (8) . 

The Task Force analysis of national mortality data for Asian/ 
Pacific Islanders under age 45 indicates that the relative risk of 
death for almost every cause is low. Although the risk of death for 
all causes is a third lower than that of Whites, Asian/Pacific 
Islanders have higher rates for TB, hepatitis, anemia, and 
hypertension. The importance of the increased risk indicated by 
relative risk for hypertension, though not large (1.2 for males and 
1.3 for females), cannot be ignored because of the impact of 
hypertension on other diseases. 

An analysis by Yu, Chang, Liu, and Kan (3) commissioned by the 
Task Force provides results of excess death analyses for the three 
major Asian subgroups: Chinese, Japanese, and Filipinos. The authors 
emphasize the lack of data for other Asian/Pacific Islander subgroups, 
such as Southeast Asians and Native Hawiians , whose health status is 
believed to be poorer than that of those Asians for whom data are 
available. The study found no "substantial amount of- excess deaths 
for a majority of the causes of death. . . [with the only consistent 
pattern being]... the high suicide rate of Chinese women vis-a-vis 
White women." Differences in socioeconomic status, culture, and 
lifestyle are hypothesized to explain the lower relative mortality of 
Asian/Pacific Islanders in the United States. The extremely low 
relative risks of death for causes generally associated with cigarette 
smoking and alcohol consumption bolster this claim. The lower 
mortality rates were analyzed separately for the Chinese, Japanese, 
and Filipinos, with the same generally favorable outcome relative to 
Whites for each. 

Relative risks of selected causes of morbidity based on 
prevalence rates from the NHIS are unavailable. Fewer than 5,000 
Asian/Pacific Islanders were sampled in the period 1979 to 1981. When 
age, sex, and cause of illness are examined, the number of responses 
on which to base population estimates is insufficient. 



83 



Papers by True (9), Yu, Chang, Liu, and Kan (3), and by Yu, Liu, 
and Kurzeja (10), commissioned for the Task Force, examine the health 
problems of immigrant and ethnic groups within the Asian population 
more closely. Cultural differences and language difficulties are 
major barriers for immigrants and refugees for using existing health 
services in the areas where they reside. Additionally, for almost 
every age group, the death rates for foreign-born Chinese, Japanese, 
and Filipinos are higher than for native-born Americans of these same 
subgroups . 

As a group, the Asian/Pacific Island population in the United 
States is at lower risk of early death than the White population. 
There are, however, specific diseases for which this population is at 
higher risk. There are also significant subgroups in this population, 
e.g.. Southeast Asians, other recent immigrants and refugees, and 
Native Hawaiians and Pacific Islanders, who have specific health 
problems that are not reflected in national data. These issues are 
discussed in more detail in Subcommittee reports found in a later 
volume of this report. 

Summary 

The data reviewed by the Task Force clearly show that Blacks have 
the greatest disparity in mortality and morbidity among the minorities 
as compared to Whites. This disparity is evident in life expectancy 
at birth, and is reflected in excess deaths as well as other measures 
of mortality and morbidity. Data for Hispanics cover only a limited 
segment of this minority; they do, however, indicate disparities in 
mortality. National mortality data, including the calculation of 
excess deaths and relative risks, indicate major areas of disparities 
between Native Americans and the White majority, perhaps most 
prominently due to several causes related to alcohol abuse. When data 
from many of the Asian/Pacific Islander subgroups are aggregated, a 
negligible disparity only is evident. However, data from the 
individual ethnic subgroups, when considered separately, suggest a 
different picture--one of a range of health problems and disparities 
in certain subgroups . 

The data used in compiling other health indicators for minority 
groups are uneven and far from complete. Nevertheless, the results 
provide a basis from which further data collection efforts and 
analyses may be made. Data on morbidity and other health status 
indicators in the four minority groups are: the most complete and 
accurate for Blacks; very limited for Asian/Pacific Islanders; 
available for American Indians and Alaska Natives living on or near 
reservations (through the Indian Health Service); and available on 
Hispanics through the surveys of NCHS, primarily the NHIS and the 
HHANES. The data currently available for Asian/Pacific Islanders and 
Hispanics may be weighted toward the larger, more established, 
healthier, ethnic groups within these minorities, rather than the less 
settled, immigrant and refugee subgroups. 



84 



Homicide, unintentional injuries, and alcohol abuse, a precursor 
to cirrhosis, stand out as primary causes of the disparity in 
mortality that are amenable to health promotion and education 
programs. Similarly, infant mortality rates in minorities may be 
improved with increased availability of prenatal counseling and 
services. Positive results of such services among the American 
Indians are already reflected in IHS statistics on neonatal deaths, 
although postneonatal deaths remain a problem. 

Hypertension, a subject of major public health initiatives at 
present, clearly is an area deserving continued emphasis in the 
minority population. Diabetes is another significant health problem 
for Blacks, American Indians, and Hispanics . The magnitude of the 
diabetes problem is often underestimated because mortality statistics 
understate the relationship of the disease to other health problems, 
especially as a risk factor for cardiovascular disease. Yet, the 
complications of diabetes can be controlled by intervention efforts. 

Only limited information exists to determine the possible 
association between health status and socioeconomic factors, such as 
income and education. Greater awareness of this relationship would 
make it possible to target existing resources more effectively toward 
the areas of greatest need in the various minority populations at risk. 



85 



REFERENCES 

1. Haynes , M. A. (1984, June 7). Presentation to the Task Force on 

Black and Minority Health, DHHS . 

2. National Center for Health Statistics. (1984). Final mortality 

statistics, 1982 . Hyattsville, MD: Author. 

3. Yu, E., Chang, C-F., Liu, W. T. , & Kan, S. H. (1984, December 5). 

Asian-White mortality differentials: Are there excess 
deaths ? Unpublished manuscript. Task Force on Black and 
Minority Health, DHHS. 

4. Haynes, M. A. (1985) Association of health problems with 

ethnic groups as reflected in ambulatory care 

visits. Unpublished manuscript, Task Force on Black and 

Minority Health, DHHS. 

5. Rumbaut, R. (1984) The politics of migrant health care: 

A comparative study of Mexican immigrants and 
Indochinese refugees in San Diego County . Unpublished 
manuscript, University of California, San Diego. 

6. Bradshaw, B. S., Frisbie, W. P., & Eifler, C. W. (1984). Excess 

and deficit mortality due to selected causes of 
death and their contributions to differences in life 
expectancy of Spanish-surnamed and other White males: 
1970 and 1980 . Unpublished manuscript. Task Force on 
Black and Minority Health, DHHS. 

7. Trevino, F. M. , & Moss, A. J. (1984, September). Health 

indicators for Hispanic, Black, and White Americans . 

(DHHS Publication No. (PHS) 84-1576). Washington, DC: National 

Center for Health Statistics. 

8. Chung, C. S., & Michael, J. M. (1984). Analysis of mortality 

and morbidity of native Hawaiians and the Pacific 
Islanders . Honolulu: University of Hawaii School of 
Public Health. 

9. True, R. H. (1985, January 11). Health care service 

delivery in Asian American communities . Unpublished 
manuscript. Task Force on Black and Minority Health, DHHS. 

10. Yu, E., Liu W. T., & Kurzeja P. (1985, January 11). Physical 

and mental health status indicators for Asian/Pacific 
Americans. Unpublished manuscript, Task Force on 
Black and Minority Health, DHHS. 



86 



Accounting For the 
Health Status Disparity 



Subcommittee 
Summary Reports 





SUBCOMMITTEE ON CANCER 
EXECUTIVE SUMMARY 



Introduction 

This report examines cancer mortality in minorities, with 
particular emphasis on factors that contribute to excess mortality; 
i.e., cancer incidence and survival, risk -factors/exposures , health 
resources, and other factors. The report illustrates the complex 
relationship among cancer incidence, survival, and mortality for 
minorities and nonminorities . 

Patterns of cancer distribution among U.S. population groups 
vary according to racial and ethnic background. In examining these 
differences, this report looks at information regarding incidence, 
mortality, and survival; information relating to prominent factors 
that are risks for cancer development; and information on knowledge, 
attitudes, and practices regarding cancer that influence care-seeking 
behavior. In short, differences in cancer experience among minorities 
and factors that may contribute to the differences between minorities 
and nonminorities are discussed. 

Risk factors are discussed because they are critical to the 
understanding of endogenous and exogenous conditions that may pre- 
dispose a person to cancer development. Major risk factors--tobacco, 
the combined effects of tobacco and alcohol, nutritional and dietary 
factors, and occupation- -account for approximately 72 percent of 
cancer mortality and 69 percent of incidence (1). 

Socioeconomic status is also an important factor in 
cancer incidence and survival and, therefore, mortality. 
Socioeconomic status is related to a variety of factors which 
influence cancer experience, including: nutritional status; smoking 
patterns; distribution, quality, and use of health resources; and 
knowledge, attitudes, and practices. Lower socioeconomic status has 
been correlated with poorer survival from cancer (2,3). It is also 
related to increased cancer incidence for cancers of the lung, breast, 
and cervix (4) . 

Most statistics relating to cancer incidence and survival rates 
are derived from the Surveillance, Epidemiology, and End Results 
(SEER) Program of the National Cancer Institute (5). The SEER Program 
obtains cancer patient incidence and survival information from 11 
population-based cancer registries that cover more than 13 percent of 
the U.S. population. Within the racial and ethnic groups in the 
United States, SEER data cover 12 percent of nonminorities, 12 percent 
of Blacks, 27 percent of Native Americans, 32 percent of Chinese, 47 
percent of Japanese, 38 percent of Filipinos, 12 percent of Hispanics, 
and 31 percent of "other". The areas covered by SEER include five 



87 



states (Connecticut, New Jersey, New Mexico, Utah, and Hawaii), four 
metropolitan areas (Atlanta, Detroit, San Francisco, and Seattle), and 
the Commonwealth of Puerto Rico. SEER data on Hispanics in this 
report, however, refer only to those Hispanics living in the United 
States. Mortality data are derived from the National Center for 
Health Statistics (NCHS) through the national vital statistics' 
system. This system classifies Hispanics as Whites, and therefore no 
death statistics on Hispanics are presented. Most of the indepth 
analysis underlying this report is limited to Blacks and Whites. The 
reason for this is that the number of cancer cases is too few in the 
other minority groups to permit meaningful statistical analysis. 

Risk Factors and Exposures 

Risk factors and exposures are important in explaining and 
accounting for the initiation and/or rise of cancers in minority and 
nonminority populations. 



The major risk factors/exposures that account for 72 percent of 
all cancer deaths are tobacco, dietary/nutritional factors, 
occupation, and ethanol, as seen in Table 11 (1). Of these, tobacco 
the greatest risk factor for cancer for Blacks. 



IS 



Table 11 



Proportion of Cancer Deaths Attributed to Different Factors 



Factors 



Estimated 

Percent of All Cancer Deaths 



Tobacco 
Alcohol 
Diet 
Occupation 



30% 

3% 

35% 

4% 



SOURCE: Doll and Peto, The Causes of Cancer (1). 



Tobacco-related cancers account for approximately 45 percent of 
new cancer cases (incidence) in Black males, 25 percent in Black females, 
and approximately 37 percent of cancer deaths in Black males and 20 
percent in Black females. 



88 



i 



Examination of tobacco use patterns indicates a higher prevalence 
of smoking in Blacks compared to Whites. However, Blacks tend to be 
lighter smokers (fewer pack years) than Whites. In view of these 
patterns, the contribution of other risk factors (e.g., diet and 
occupation and their combined effects with tobacco) gain added 
importance, particularly in explaining excess lung cancer mortality in 
Black males. 

The contribution of occupational exposures to cancer etiology in 
minorities may be even greater than the 4 percent listed in Doll and 
Peto (1). Numerous occupational epidemiology studies document the 
higher rate of assignment of Blacks to hazardous worksites compared 
with rates for Whites. This fact, coupled with the excessive cancer 
experiences of Blacks, suggests occupation may likely account for a 
greater percentage of cancers in minorities than previously 
appreciated (6) . 

Knowledge, attitudes, and practices are important to 
understanding factors that relate to people seeking care for cancer 
(cancer screening, detection, treatment, and rehabilitation). 
National surveys indicate that Blacks overestimate the deadliness of 
cancer and underestimate cancer prevalence in their population. 
Additionally, Blacks are less knowledgeable about cancer-related 
warning signs and screening methods than Whites. Even with early 
detection. Blacks are more pessimistic about the curability of cancer 
than Whites (7). Such disparities in knowledge, attitudes, and 
practices between Blacks and nonminorities may help to explain the 
longer delay in seeking diagnosis and treatment among Blacks and thus 
the greater prevalence of more advanced stages of cancer in Blacks 
than in Whites (5). More advanced stages of cancer have unfavorable 
prognosis for cancer survival. 

Cancer in Minority Groups 

Blacks are the largest minority population in the United 
States and the one for which the most cancer data are available. 
However, where relevant reliable information is available for other 
minority groups - -Hispanics , Asian/Pacific Islanders, and Native 
Americans--it will be presented. Blacks have the highest overall 
age-adjusted cancer rates for both incidence and mortality of any U.S. 
population group. Figure 6 illustrates the average annual mortality 
rate for cancer, by sex and race. 

Table 12 shows the average annual incidence rates (detecting new 
sites of cancer) according to selected primary sites and racial/ethnic 
groups. The most recent SEER cancer incidence data, 1978-81, show an 
11 percent excess incidence of cancer among Black Americans compared 
with nonminority Americans. The age-adjusted incidence rate is 25 
percent higher among Black males compared with nonminority males, and 
4 percent higher among Black females compared with nonminority 
females. Black men showed the largest increase (8 percent) in cancer 
mortality between 1973-77 and 1978-81. 



89 




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Blacks experience greater age -adjusted incidence rates than 
nonminorities for cancers of the cervix, esophagus, larynx, pancreas, 
prostate, and stomach. Excess mortality exists for cancers of the 
following sites: bladder, cervix, corpus uterus, esophagus, lung, 
prostate, and stomach. Excess incidence and mortality are particularly 
pronounced among Black males. 

SEER data are available for 25 primary cancer sites. Blacks 
have lower survival rates than nonminorities for 22 of those cancers (5) 
Five-year relative survival for all cancer sites combined is 12 
percent less in Blacks than in Whites (38 percent versus 50 percent, 
respectively). Blacks survive less for cancers of the bladder, 
breast, corpus uterus, prostate, and rectum. 

Blacks 

Table 13 shows average annual cancer mortality rates by selected 
primary sites and race. The death rate for lung cancer is 45 percent 
higher among Black males compared to nonminority males. The death 
rate for both Black and nonminority females is about equal. For 
cancer of the esophagus among Black males, mortality is three times 
higher than for nonminority males. Mortality rates among Black women 
are 2.5 times higher than for nonminority women. Age-adjusted 
incidence rates of esophageal cancer are correspondingly high: 3.5 
times higher for Black men compared with nonminority men, and almost 3 
times higher in Black women than nonminority women. Mortality from 
stomach cancer is more than 1.5 times greater among Blacks than among 
nonminorities. Stomach cancer incidence is almost twice as high among 
Blacks compared with nonminorities. 

Age-adjusted mortality from prostate cancer is two times higher 
among Black males than among nonminority males. The death rates 
increased by 11.8 percent among Blacks and only 4.2 percent among 
nonminorities between the periods 1973-77 and 1978-81. Incidence data 
show that Black men have a 60 percent excess incidence of prostate 
cancer compared with nonminority men in the United States . 

Both mortality and incidence rates for cervical cancer are 
approximately 2.5 times higher among Black females than among 
nonminority females. Nonminority females showed a 20 percent decrease 
in cervical cancer deaths between 1973-77 and 1979-81, while Black 
females experienced a 27 percent increase during this same period. 
Black females experienced a 33 percent excess death rate from cancers 
of the corpus uteri compared with nonminority females. 

The incidence of multiple myeloma is more than twice as high for 
Blacks than for nonminorities. The incidence for Black men is 9.6 per 
100,000 and for Black women it is 6.7. The rate for nonminority men 
is 4.3, and for nonminority women it is 3.0. 



92 



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93 



There are striking differences in Black/nonminority survival for 
cancers of certain sites. Table 14 shows relative 5-year survival 
rates for selected sites of cancer. The 5-year relative all-site 
survival rate for 1976-81 was 50 percent for nonminorities and 38 
percent for Blacks. Of the 25 primary cancer sites for which survival 
data were available, Blacks had better 5-year relative survival than 
non-minorities for only three sites--ovary , brain, and multiple 
myeloma--all relatively low-incidence cancers. Black patients had 
better survival rates than nonminorities for ovarian cancer for all 
stages combined and also within each stage category. 

The breast cancer survival difference (Blacks, 63 percent; 
nonminorities, 75 percent) was statistically significant. This was 
partly related to the large number of Blacks who had lymph node 
involvement or direct extension of tumors to adjacent tissue at the 
time of diagnosis (stage III B). The difference in 5-year relative 
survival rates for Blacks and nonminorities for all stages combined 
for colon cancer and bladder cancer was significant, with Blacks 
experiencing lower survival rates. 

The scientific literature supports a hypothesis that the 
differences in cancer experience between nonminorities and Blacks may 
be largely attributable to social or environmental factors rather than 
inherent genetic or biologic differences (4,8,9). This has major 
policy ramifications for the accessibility, availability, utilization, 
quality, and continuity of health resources, for example, state-of-the-art 
cancer screening, detection, treatment, and rehabilitation. Other 
possible contributors include: nutritional status and dietary 
patterns; immune status and function; educational level and attitude, 
and awareness of cancer preventive concepts and behaviors; and 
acceptance of cancer as a real and potential threat. 

When adjustments are made for stage at diagnosis in cancer 
patient survival studies, survival differences decrease between Blacks 
and nonminorities (10), and when adjustments for socioeconomic status 
are made, the disparities between the two groups are further reduced 
(2,3,8,11). Factors that may contribute to poor cancer survival in 
Blacks include lower socioeconomic status (11), later stage at diagnosis, 
delay in detection and treatment (10), treatment differences (12) 
and biologic factors such as immune competence and response, 
histologic patterns of tumors, and nutritional status (13). 

Hispanics 

Overall age-adjusted cancer incidence rates for Hispanics are 
lower than for Blacks or nonminorities. Specific sites of excess 
incidence among Hispanics are stomach, prostate, esophagus, pancreas, 
and cervix cancers . Stomach cancer incidence in Hispanics is twice 
that of nonminorities. Stomach cancer incidence has been correlated 
with diets high in smoked, pickled, and spiced foods--especially those 
high in N-nitroso compounds. Tobacco also has been suggested as a 
risk factor in stomach cancer development. New Mexico Hispanics have 



94 



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95 



pancreatic cancer rates that are higher than those of nonminorities . 
An upward trend also is appearing for Puerto Rican females. Excess 
risk for pancreatic cancer has been found among cigarette smokers. 
Also, cervical cancer is twice as high among Hispanics as among 
nonminorities. The incidence among Hispanics is, however, lower than 
that for Blacks, Native Americans, and Chinese Americans. 

The overall 5 -year relative survival rate of Hispanic males is 
almost identical to that of nonminorities. Hispanic females have 
somewhat lower survival rates than that of nonminority females. 
Survival data are similar for Hispanics and nonminorities for all 
sites except bladder cancer and Hodgkin's disease, where survival is 
poorer for Hispanics, and ovarian cancer, where it is poorer for White 
non-Hispanics (14). 

Asian/Pacific Islanders 

Cancer incidence varies widely among Americans of Chinese, 
Japanese, Filipino, and Hawaiian descent. Rates of cancer incidence 
among Hawaiians follow Blacks with the second highest in the U. S. 
population. The rates for Chinese, Japanese, and Filipinos are less 
than for nonminorities. There is, however, an upward trend in 
incidence rates for both sexes of the Chinese population and for 
Japanese males. Hawaiians have excess mortality for cancers of the 
breast and lung. Japanese Americans have excess mortality for stomach 
cancer. Chinese Americans have excess rates for cancer of the cervix 
and for nasopharyngeal cancer. Among Chinese and Japanese, rates for 
males are higher than those for females (15). 

Stomach cancer incidence is 2.5 times higher for Japanese males 
and 3.8 times higher for females than for nonminority males and 
females. Esophageal cancer is also 2.5 times higher in Japanese males 
compared with nonminorities. Migratory studies of Japanese point to 
dietary practices as a cause in three major cancer sites: stomach, 
breast, and colon. Japanese females are the only U.S. minority group 
that does not have cervical cancer incidence rates above that of 
nonminorities. However, Japanese females show a trend toward higher 
rates . 

Chinese Americans have an increased incidence of about 17 
percent over nonminorities of multiple myeloma. Incidence of 
esophageal cancer is higher for Chinese males and females than for 
nonminorities. Most studies on the causes of esophageal cancer 
suggest that the major risk factors are smoking and alcohol 
consumption, with the combined use having a synergistic effect. 
Consumption of hot beverages also has been implicated in esophageal 
cancer. Pancreatic cancer incidence is about 20 percent higher among 
Chinese females than among nonminorities, and an upward trend in 
incidence exists for Chinese of both sexes. Excess risk for 
pancreatic cancer has been found among cigarette smokers. 



96 



Filipinos have the lowest survival of all ethnic groups for 
colon cancer (35 percent) and the highest for ovarian cancer (35 
percent) . Hawaiians experienced comparatively high survival rates for 
lung, breast, prostate, and cervix cancer and comparatively lower 
survival rates for ovarian (38 percent) and corpus cancers (76 
percent) . 

SEER registry data (1973-79) indicate that for Chinese Americans 
the 5-year relative survival for all sites was 35 percent in males and 
50 percent in females compared with 40 percent and 55 percent in 
nonminorities . In Filipino Americans, site-specific relative survival 
rates vary widely, with some rates being the lowest of eight ethnic 
groups and others being much higher. Survival rates for Hawaiians 
also vary widely, as noted above. 

Native Americans 

Native Americans have the lowest rates of overall cancer 
incidence and mortality of all U.S. populations (including 
nonminorities) covered in the SEER program. Cause of death data 
indicate that cancer, the second leading cause of death for the U.S. 
population as a whole, is the third most common cause of death 
(preceded by accidents and heart disease) among Native Americans. In 
1975, the age-adjusted mortality for cancers was 39 percent lower for 
this group than for the general U.S. population (16). 

However, Native Americans generally had low survival rates 
according to 1973-79 SEER data. Overall 5-year relative survival for 
males was 26 percent compared with 40 percent for nonminority males, 
and 39 percent for females compared with 55 percent for nonminority 
females. Native Americans have rates below nonminorities for the most 
common cancers --lung, colon, breast, and prostate cancer--and much 
higher rates for cancers of the cervix, gall bladder, and kidney. 
Differences in overall cancer mortality for Native Americans and 
nonminorities are believed to be due more to cultural factors and 
environment than to genetic factors. 

The lung cancer mortality among Oklahoma tribes is nine times 
greater than that of Southwest tribes . Environmental and cultural 
factors, in this case, heavy smoking among Oklahoma Indians but not 
among Southwest tribes, undoubtedly play a role in this discrepancy. 
Indians of the Southwest, who seldom smoke extensively, have low rates 
of squamous cell bronchogenic carcinoma--a common type of lung cancer 
and the one associated with heavy smoking (16). 

Native Americans show excess mortality for cancer of the gall 
bladder. Indians of the Southwest have the greatest incidence as 
compared with Oklahoma Indians. The excess incidence of cancer of the 
gall bladder is frequently attributed to a genetic basis. Native 
Americans also have excess mortality from cancer of the cervix. Alaska 
Natives are reported to have increased incidence of cancer of the gall 
bladder and excess mortality from primary liver cell cancers (17). 



97 



OPPORTUNITIES FOR PROGRESS 

Many of these activities, proposed by the Subcommittee on 
Cancer, are also applicable to the United States population in 
general, not just to minorities. 

Information and Education 

Increase the public's knowledge of the health hazards of tobacco 
through activities originating in the Office on Smoking and Health. 

Design smoking cessation programs targeted specifically to the 
underserved working population (migrant workers, recent immigrants, 
part-time workers, shift workers). 

Continue to publicize the risks of smoking and tobacco use through the 
Office of Cancer Communications (and its Cancer Prevention Awareness 
Program and other National Cancer Institute (NCI) programs). 

Continue to inform the public, through the Cancer Information Service 
(CIS) , about resources available to prevent and stop smoking and 
tobacco use. 

Assist and promote an increased role for the NCI-sponsored 
Comprehensive Cancer Centers in prevention and cessation of smoking 
and tobacco use. 

Develop joint efforts between the Federal Government and industry to 
develop diet and cancer programs that use mass media and other 
high- techno logy communication approaches. 

Target primary care physicians and other primary care health 
professionals (for example, pharmacists, occupational nurses) for 
educational campaigns about the importance of screening and early 
detection. Specific educational messages for these groups should 
include: 

• The importance of comprehensive physical examinations to detect 
cancers of the rectum and prostate (digital rectal examination) , 
breast (palpation and mammography), skin (physical examination), 
cervix and uterus (pelvic examination and Pap smear) , and 
endometrial sampling in high-risk females to detect uterine 
cancer. 

• The importance of identifying and closely monitoring: high-risk 
individuals with aggressive follow-up where changes are apparent; 
any history of nonmenstrual bleeding in women, with aggressive 
follow-up; and family history to determine risk for breast 
cancer and melanoma; 



98 



• The importance of early referral for diagnosis and treatment 
planning. 

• The fact that many forms of cancer are treatable and curable. 

Emphasize through teachers' associations and appropriate clubs, 
lay organizations, and churches the value of screening for cancer in 
their efforts to inform and educate the public and their members. 

Use radio and television and other media programs more 
effectively to present information on the value of screening for 
cancer. These program efforts should make special attempts to target 
messages to high-risk groups, such as those exposed to known 
carcinogens and those with a strong family history of cancer (breast 
cancer, ovarian cancer, and melanoma). The messages should be 
sensitive to the special cultural and social settings of the people 
who need to be reached. All public education programs should 
emphasize: 

• The importance of early warning symptoms of cancer. 

• The importance of comprehensive physical examinations. 

• The appropriateness and importance both of seeking information 
about treatment choices and seeking referrals when appropriate. 

In educational efforts regarding cervical cancer, include informa- 
tion on risk factors for the disease and on the importance of follow-up for 
abnormal bleeding, as well as on the availability and usefulness of the Pap 
test. The importance of pelvic examinations and follow-up for abnormal 
bleeding should be emphasized in public education campaigns about uterine 
cancers; such efforts should be targeted to postmenopausal women, especially 
those with lower socioeconomic status. 

Public information programs about colon, rectal, and prostate cancer 
should emphasize: 

• The high risk of these cancers for adults aged 50 and above. 

• The importance of early recognition of symptoms. 

Try innovative channels of communication, for example, 
mailing information on colon, rectal, and prostate cancer with social 
security checks to reach retired elderly persons, and distributing literature 
at retail stores and pharmacies. 

Strategies for disseminating information to professionals should 
include all the traditional methods, such as professional meetings, 
journals, special continuing medical education symposia and consensus 
conferences, revised medical school curricula, and residency training. 



99 



Use the Physician Data Query (PDQ) system should be used as a 
vehicle for disseminating up-to-date cancer treatment information to 
physicians . 

Capacity Building in the Non-Federal Sector 

DHHS should work with the non-Federal sector in developing the 
capacity to perform periodic surveys on the prevalence of smoking to 
assess problems and progress. 

Encourage state health agencies to develop and implement 
statewide, health-risk appraisals/risk reduction programs that include 
smoking as a risk factor. 

Encourage state education departments to review and evaluate 
elementary and secondary school health and home economics curricula 
and training guides. Draw upon appropriate local and national experts 
to upgrade curricula to reflect newer knowledge of diet and cancer 
risks and strategies for risk reduction. 

Encourage state and local governments to assist voluntary and 
private sector groups in modifying existing health promotion programs 
to include diet and cancer risk reduction components. 

Encourage state and local agencies for agriculture, environmental 
protection, health, and aging to coordinate program planning 
activities to ensure that attention is given to reducing dietary risk 
factors for cancer. One such activity would be to include education 
and information on eating for better health and for avoiding cancer 
risk, and to make use of innovative approaches to reach high-risk 
groups . 

Voluntary health organizations should continue to expand their 
efforts to increase the utilization of screening for cancer and should 
develop programs to overcome identified impediments to utilization. 
These groups should be the focus of other prevention activities. 

As appropriate, hospitals should consider adopting mechanisms 
that would promote screening tests such as breast examination, the Pap 
smear, the stool occult blood test, and rectal examination at some 
time during admission or prior to completion of treatment in the 
emergency room for most patients. 

Financing Issues 

Encourage employers to include screening for cancer according to 
specified protocols as a component of their health care packages. 

Health insurers should remind their clients about cancer 
screening recommendations. 



100 



Life insurers should offer rate incentives to clients who 
participate in recommended cancer-screening activities, and purchasers 
of large amounts of insurance should be encouraged to request thsse 
incentives . 

Explore incentives that might offer health care providers 
reimbursement for comprehensive diagnostic workups, adequate clinical 
staging prior to treatment, appropriate multidisciplinary referrals, 
and application of state-of-the-art detection, treatment, and 
rehabilitation. 

Health Professions Development 

The curricula of medical students and ongoing education programs 
for physicians and health care providers should include information 
regarding the health consequences of smoking and tobacco use and 
prevention and cessation methods. The collaboration of medical and 
health professional associations (particularly associations of 
minority physicians and other health professionals) in this process 
would further facilitate this effort. 

Physicians and other health care providers should be encouraged 
to serve as role models by refraining from tobacco use. 

Physicians and other health care providers should offer 
interventions to heavy smokers; patients with lung disease, heart 
disease, cancer, or alcohol dependence; and patients in occupations 
with high risk for cancer. 

Active cancer-screening programs for demonstration and teaching 
purposes should be incorporated into the educational programs of 
medical and other health professional schools. 

Educational programs for health professionals and physicians in 
residency training should promote cancer screening. 

Educational messages to specialty physicians should emphasize the 
importance of: 

• Aggressive workups (radiology and endoscopy) for occult blood. 

• Disease staging prior to treatment for all cancers, especially 
rectal, colon, breast, prostate, small-cell lung, cervical, 
uterine, ovarian, and skin (melanoma) cancer. 

Professional oncology education should be enhanced by 
institutions through the Physician Data Query (PDQ) system, oncology 
nursing support, treatment guidelines, protocol participation, and 
quality assurance requirements by the Joint Commission on 
Accreditation of Hospitals. 



101 



Federal Leadership in Work with Other Sectors 

Promote comprehensive health education, emphasizing avoidance of 
smoking and other high-risk behavior, from kindergarten through 
grade 12. 

Make model smoking cessation programs available, through the 
Office of Smoking and Health, to students, faculty, and staff of 
interested educational institutions. 

The establishment of a "peer corps ' of high-school seniors 
interested in practicing health promotion should be encouraged; these 
students could be given incentives such as scholarships and could play 
a significant role in smoking prevention and cessation at the local 
level. 

Explore collaborative efforts between DHHS and such associations 
as health maintenance organizations, the American Hospital 
Association, and local hospitals to develop hospital-based cessation 
and prevention programs. These organizations could participate in 
efforts to discourage the sale of cigarettes in hospitals, nursing 
homes, other health care facilities, and pharmacies. 

Corporate and union leaders should collaborate to develop and 
promote model nonsmoking standards as an integral part of worksite 
health promotion and fitness programs. 

Insurance companies should be encouraged to establish and expand 
nonsraoker differential rates for health, life, and home insurance. 

Schools and programs of occupational medicine should be 
encouraged to include smoking cessation in their educational programs. 

Federal meat and milk grading programs should work with producers 
to expand production and marketing of leaner, low-fat products. For 
example, the red meat industry has proposed new grading standards that 
permit the choice and prime grades to be leaner, which would result in 
less fat in American diets . 

Senior citizen organizations should seek health care 
organizations that provide low-cost but technically skilled screening 
programs and should actively encourage their members to use these 
screening programs. 

Research Issues 

Promote close collaboration in research by developing a network 
among smoking intervention researchers funded by the NCI Smoking, 
Tobacco, and Cancer Program. 



102 



Involve NCI -sponsored researchers of smoking interventions in NCI 
year 2000 activities, especially the application of findings that come 
from their research. 

Intensify research on selective livestock breeding to produce 
leaner food products . 

Conduct research to enhance the quality and desirability of 
fiber-rich foods, including cereals and breads. 

The NCI should support research on cancer screening technology 
and on utilization of screening techniques. 

Data 

To track progress in controlling cancer in all populations and 
especially in the minorities, baseline information and monitoring on a 
regular basis of the following indicators should be undertaken: 
incidence, mortality, stage at diagnosis, and relative survival by 
cancer site; percent of adults and children who smoke and for former 
smokers, the time since quitting; the percent of fat and fiber in the 
diet and the percent who are obese; the percent of eligible persons 
who are screened for cancer; percent of cancer patients treated by 
state-of-the-art methods; percent of workers exposed to carcinogens in 
the workplace as well as the percent of those who are screened in the 
workplace; and the percent of the population and ethnic groups with 
particular knowledge, attitudes, and beliefs about cancer. 

Improve surveillance and registration of occupational exposure. 
Link registration to current cancer surveillance systems. 

Improve the timeliness of mortality data reported by the NCHS so 
that data for a given year will be available by the end of the 
following year. 

Obtain data on smoking habits on an annual basis and on knowledge 
and beliefs about cancer on a biennial basis through the National 
Health Interview Survey (NHIS). 

NCI should take the lead in helping population-based cancer 
registries achieve compatibility with SEER and help them to improve 
data quality. 

Augment existing national surveys rather than conduct new ones. 

The Centers for Disease Control should explore the possibility of 
using the Morbidity and Mortality Weekly Report or the 121 City 
Mortality System for monitoring cancers that are amenable to 
rapid intervention. 



103 



Continue the longitudinal study of the Current Population Survey 
sample matched to the National Death Index. 

Explore the possibility of NCI including additional items in SEER 
such as detailed treatment information and socioeconomic status 
information. 

Install a data collection mechanism in SEER areas to obtain 
additional information from medical records or through slide review as 
specific questions arise. 

Supplement ongoing population surveys (preferably the NHIS) with 
questions on cancer screening. 

Consider including one or more questions on smoking in the 1990 
census . 

Conduct special surveys, under the direction of NCI, to obtain 
data on the general population in specific geographic areas. 

Conduct population surveys to obtain detailed data for various 
surveillance indicators in SEER areas or in other areas with 
population-based cancer registries so that indicators can be 
correlated with measures of outcome. 



104 



REFERENCES 

1. Doll, R., & Peto, R. C1981). The causes of cancer . New 

York, NY: Oxford University Press. 

2. Linden, G. (1969). The influence of social class in the survival 

of cancer patients. American Journal of Public Health , 
59, 267-274. 

3. Lipworth L. (1970). Socioeconomic factors in the prognosis of 

cancer patients. Journal of Chronic Diseases , 23 , 105-116. 

4. DeVesa, S. S., & Diamond, E. L. (1980). Association of breast 

cancer and cervical cancer incidences with income and 
education among Whites and Blacks. Journal of the National 
Cancer Institute , 65(3), 515-528. 

5. National Cancer Institute. (1985). Cancer incidence and 

mortality in the United States, 1973-1981 (NIH 
Publication No. 85-1837). Bethesda, MD: U.S. Department 
of Health and Human Services. 

6. Miller, W. , & Cooper, R. (1982). Rising lung cancer death 

rates among Black men: The importance of occupation and 
social class. Journal of the National Medical 
Association , 74(3), 253-258. 

7. EVAXX, Inc. (1980). A study of Black Americans' attitudes 

toward cancer and cancer tests . New York, NY: American 
Cancer Society. 

8. Dayal, H. H. , Power, R. N., & Chiu, C. (1982). Race and 

socioeconomic status in survival from breast cancer. 
Journal of Chronic Diseases , 35, 675-683. 

9. Graham, S., &. Schotz, W. (1979). Epidemiology of cancer of the 

cervix in Buffalo, New York. Journal of the National 
Cancer Institute , 63(1), 23-27. 

10. Wilkinson, G. S. (1979). Delay, stage of disease, and survival 

from breast cancer. Journal of Chronic Diseases , 32, 
365-373. 

11. Berg, J. W. (1977). Economic status and survival of cancer 

patients. Cancer , 39, 467-477. 

12. Page, W. F., & Kuntz, A. J. (1980). Racial and socioeconomic factors 

in cancer survival: A comparison of Veterans' Administration 
results with selected studies. Cancer, 45, 1029-1040. 



105 



13. Savage, D., Lindenbaum, J., Osserman, E., Van Ryzin, J., 

& Garrett, T. (1981). Survival of Black and White patients 
with multiple myeloma at two hospitals [Abstract]. 
Proceedings of the American Association of Cancer 
Research , 22, 537. 

14. Young, J. L. , Jr., Ries , L. G. , & Pollack, E. S. (1984). Cancer 

patient survival among ethnic groups in the United States. 
Journal of the National Cancer Institute , 73(2) , 
341-352. 

15. Thomas, D. B. (1979). Epidemiologic studies of cancer in 

minority groups in the Western United States. National 
Cancer Institute Monographs , 53, 103-113. 

16. Sievers, M. L. , Fisher, J. R. (1981). Diseases of North 

American Indians. In H. Rothschild, & C. Chapman (Eds.), 
Biocultural aspects of disease (pp. 191-252). New York, NY: 
Academic Press . 

17. Boss, L. P., Lanier, A. P., Dohan, P. H. , & Bender T. R. (1982). 

Cancers of the gall bladder and biliary tract in Alaska 
Natives. Journal of the National Cancer Institute , 
69,(5), 1005-1007. 



106 



SUBCOMMITTEE ON CARDIOVASCULAR AND 
CEREBROVASCULAR DISEASES 

EXECUTIVE SUMMARY 

Introduction 

This report reviews cardiovascular and cerebrovascular diseases 
in Black Americans and, to a lesser extent because of the paucity of 
information, in Hispanics , Native Americans, and Asian/Pacific 
Islanders. Heart diseases and stroke cause more deaths, disability, 
and economic loss in the United States than any other acute or chronic 
diseases and are the leading causes of days lost from work. This 
observation is true, not only for the general population, but for each 
of the four minority populations in this report (1,2,3). The data to 
extend this statement to the many subgroups of each minority do not 
exist, but cardiovascular disease (CVD) remains an unquestionably 
important health issue for each. 

Even though currently available data are insufficient for excess 
deaths to be calculated for each minority population, average annual 
death rates for heart disease are higher in Black men and women under 
age 70 than in comparable Whites. Under 45 years of age, the rates 
for Native Americans, as well as for Blacks, are higher than they are 
for Whites, in both genders (Figures 7 and 8). 

Dramatic differences exist between the levels of the various CVD 
risk factors both when minority populations are compared with each 
other and also when each is compared with the White population. The 
leading treatable risk factors for cardiovascular disease in the White 
population include hypertension, elevated blood cholesterol, cigarette 
smoking, diabetes mellitus, and obesity. Although the data are 
limited or frequently .nonexistent regarding these risk factors and 
their importance in minority health, current wisdom suggests that a 
major approach to improvement of cardiovascular and general health in 
minorities should focus on these modifiable risk factors. Major 
socioeconomic differentials also exist between minorities and Whites 
that affect their respective life experiences, biological risk factor 
distributions, and access to medical care. A comprehensive model that 
takes into account the social context of disease is required to 
clarify the causes of the observed CVD disparities, to develop 
effective therapeutic approaches, and to enhance understanding of CVD 
etiology. 

Blacks 

Coronary Heart Disease 

The burden of coronary heart disease (CHD) can be evaluated by 
several indices including: CHD mortality, prevalence (the proportion 
of people alive at a point in time who have a history of CHD) , and 



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incidence (the combination of fatal and nonfatal CHD events occurring 
over a specified period of time in a population). Curiously, these 
indices give different estimates of the magnitude of the problem in 
Blacks. CHD mortality rates are similar in Black and White men, but 
are greater among Black than White women (4). Incidence of CHD also 
shows an excess among Black women, but in several studies in the 
southern region of the United States, excess incidence was not found 
in Black men (5,6). Interestingly, the prevalence rates of CHD in 
Blacks and Whites appear similar (7). Finally, hospital admission 
records of acute myocardial infarction (MI) indicate higher rates for 
White than Black men which may result from higher rates of sudden 
death in Blacks prior to hospital admission (8). 

Hypertension 

Hypertension is a major risk factor for heart disease and stroke. 
Mean blood pressure levels are greater in Blacks than Whites with a 
marked excess of hypertension in Blacks (9). However, progress has 
been made. Between 1960-80, mean systolic pressures declined more in 
Blacks than in Whites (5). By 1980, Black adults were more likely to 
be aware of their elevated blood pressure than Whites (9). 
Hypertensive Blacks were at least as likely as Whites of the same sex 
to be treated with antihypertensive medication and nearly as likely to 
have their blood pressure controlled. The improved control of 
hypertension has almost certainly contributed to significant 
improvement in CVD status, and thus to the general health, of Black 
Americans. Despite this encouraging progress in awareness, treatment, 
and control of high blood pressure, there remains significant excess 
of hypertension in Black men and women. 

Stroke mortality of Blacks declined 51 percent, and CHD mortality 
in Blacks declined 42 percent from 1968 to 1982. Hypertension control 
has certainly been one of the factors responsible for this improvement 
in health. 

Stroke and Hypertensive End-Stage Renal Disease 

Stroke deaths are much higher among Blacks than Whites (see 
Figure 9); a greater proportion of Blacks than Whites suffers nonfatal 
strokes as well (10). End-stage renal disease (ESRD) , resulting from 
hypertension, occurs more commonly in Blacks than Whites (11); Blacks 
with hypertension are at much greater risk of developing ESRD than 
Whites. Interestingly, Blacks with hypertensive ESRD who receive 
treatment with dialysis have a more favorable cardiovascular mortality 
outlook than Whites who receive treatment. 

Other Cardiovascular Risk Factors 

Mean total serum cholesterol levels in Black and White adults are 
similar (12). High-density lipoprotein (HDL) cholesterol levels are 
consistently higher in Black men than White men, but the same is not 
true for women. 



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Smoking appears to increase the risk of CVD mortality similarly 
in Blacks and Whites (13). Cigarette smoking prevalence is greater 
among Black than White men, but the prevalence of heavy smoking is 
greater among White than Black adults (14,15). 

The impact of cigarette smoking and elevated serum cholesterol 
levels on heart disease mortality is similar in Blacks and Whites, 
although the effect of hypertension appears to be less in Blacks than 
Whites (13). Smoking cessation and prevention, and cholesterol 
reduction in Blacks should reduce the incidence of heart disease. 

The prevalence of diabetes mellitus, both diagnosed and 
undiagnosed, is greater among Blacks than Whites (16). However, the 
effects of diabetes mellitus on CVD in Black Americans have not been 
assessed adequately. 

Obesity is also common in Black women and may provide a partial 
explanation for their excess coronary disease risk (17). 

Electrocardiographic abnormalities have been found to be 
predictive of CKD in White patients (18). Such abnormalities are more 
common in Blacks than Whites (13,19). The impact of these 
abnormalities, especially electrocardiographic evidence of left 
ventricular hypertrophy (ECG-LVH) , has not been assessed 
satisfactorily in Blacks. 

Substantial efforts in hypertension control should continue to 
improve cardiovascular disease incidence and mortality in Blacks. The 
heterogeneity of blood pressure levels and hypertension prevalence in 
Black populations in Africa (20,21,22) the Caribbean (23-27), and the 
Americas (28) casts doubt on the proposition that genetic factors are 
primarily responsible for blood pressure excess in U.S. Blacks. 

Social, Cultural, and Economic Aspects 

There are persistent differences between Black and White 
Americans in education, occupational level, and income (29-33). On 
average, Blacks have fewer years of formal education than Whites. 
Those with equivalent education have access to fewer job opportunities 
than Whites (34,35). Those with equivalent employment are likely to 
be paid less than Whites. There is some evidence of a low incidence 
of coronary disease in Blacks of high socioeconomic status (SES) (36). 
Improved risk factor distributions have been associated with higher 
SES, which may account for this observation. Complicating the 
picture, however, is the impression that higher SES may be associated 
with lower levels of HDL-cholesterol . 

There is an inverse association of education with hypertension 
prevalence (37). Studies of Blacks indicate that there is an inverse 
association of blood pressure and/or incidence of elevated blood 
pressure with both income and social class (38,39). The mechanism by 
which socioeconomic status is associated with high blood pressure in 



112 



Blacks is unclear. High blood pressure has been related to residence 
in areas of high social stress and instability as well as to coping 
styles, education, and occupational insecurity. Hypertension- 
associated mortality rates also show linkages with social 
instability. The relationship between social factors and high blood 
pressure (and associated mortality rates) suggests that hypertension 
control in Black communities can be improved by interventions that are 
not strictly biomedical, but which increase levels of social support. 

Behavioral risk factors, such as diet, smoking patterns, and 
physical activity are often part of the particular cultural patterns 
that are grounded in socioeconomic circumstances associated with 
increased risk. In addition, certain cultural patterns may impede 
efforts to reduce risk. In particular, cultural factors may determine 
the effectiveness of efforts to prevent hypertension, to lower CHD 
risk by reducing risk factors, and to treat hypertension more 
effectively. 

Knowledge and Awareness of Cardiovascular Diseases 

Data on knowledge of CVD in Blacks are inadequate but suggest 
significant deficits in Blacks' knowledge concerning the association 
of CVD with diet (40). Data on Blacks' health practices important for 
CVD outcomes are scanty. A few demonstration and education research 
efforts are seeking to apply insights obtained from studies of CVD to 
Black population groups. 

The impact of education, especially of reading achievement, has 
been emphasized in some studies of cardiovascular health education. 
For example, one school-based, cardiovascular health education study 
in Chicago (41) detected racial differences in the increases in 
knowledge concerning nutrition, exercise, and smoking and their 
relationship to CVD after an intervention. Black children had a 
smaller increase in knowledge than others and, at follow-up nine 
months later, had persistently lower knowledge scores even after 
adjustment for reading achievement. Reading achievement also was 
significantly related to nutrition knowledge and attitudes, but not 
to behavior. 

Awareness of high blood pressure has increased in Blacks in the 
last decade (9), but many Blacks have significant misconceptions 
concerning factors that predispose to hypertension (42). 

Nonadherence to antihypertensive therapy is a major problem in 
achieving blood pressure control, but is not specific to Blacks. 
Determinants of nonadherence by hypertensive Black patients have been 
identified in several studies (43,44,45), and the effectiveness of a 
number of health-education strategies in enhancing adherence has been 
illustrated in studies of Black patients. 



113 



Access to Care 

Access to care is especially relevant for chronic cardiovascular 
diseases. Black Americans make fewer office visits to physicians than 
do Whites, and are less likely to be seen by CVD specialists (46) This 
may contribute to the less frequent diagnosis of coronary disease in 
Blacks. Blacks undergo coronary arteriography less frequently than 
Whites (47). Even when Blacks and Whites have coronary disease of 
comparable severity, Blacks are less likely to undergo coronary bypass 
surgery (48). Black patients are less likely than White patients to 
be seen in physicians' offices and are more likely to be seen in 
hospital clinics or emergency rooms (49). For hypertensive Black 
patients, this probably has adverse effects on the continuity of care 
received. 

Blacks have more difficulty in entering the medical care system 
than Whites and express greater dissatisfaction with services; Blacks 
perceive the medical care system to be less accessible to them (50). 
These perceptions can be changed and medical care use increased in a 
number of settings by targeted interventions. Such interventions must 
be persistent if good results are to be obtained and preserved. 

Hispanics 

Coronary Heart Disease and Stroke 

CVD is a major cause of death in Hispanics, although the rate is 
lower than in non-Hispanic Whites (2). This lower relative rate is 
unexpected given their socioeconomic profile, pronounced 
rural-to-urban migration and high percentage of immigrants, and the 
prevalence of obesity and diabetes, particularly in women. 

National epidemiological data on cardiovascular disease mortality 
in Hispanics are limited, to date. Regional CHD mortality rates for 
Mexican Americans in Los Angeles County (2) and Texas (51) are lower 
than in Whites for both sexes. The rate of decline in CHD mortality 
in Hispanics appears to have been comparable to that in Whites during 
the last decade. Compared with Whites, some preliminary regional data 
suggest lower stroke mortality rates in Mexican Americans (2) , but 
slightly higher rates among younger Puerto Ricans in New York (52). 

Hypertension 

There appears to be a strong inverse relationship between SES 
level and hypertension in Hispanics, similar to that found for Blacks 
and non-Hispanic Whites. Among Hispanic women this effect remains even 
when adjustments are made to account for the higher rate of obesity 
among those with lower SES (56) . 



114 



Other Cardiovascular Risk Factors 

Diabetes mellitus is a major problem in Hispanics , especially in 
Mexican Americans and Puerto Ricans living in the United States 
(57,58). However, the relationship between this risk factor and 
coronary heart disease has not been adequately studied in each of the 
major Hispanic groups. 

The generally higher prevalence of obesity, noninsulin-dependent 
diabetes, hypertension, high LDL-cholesterol and low HDL-cholesterol 
levels in Hispanics might be expected to increase their CVD risk. 
Evidence reviewed on the possible biological or physiological 
differences between Hispanics and Whites, however, suggests that no 
specific factor or set of factors explains why Hispanics as a group 
appear to be at lower risk for coronary heart disease, and at equal or 
slightly higher risk for cerebrovascular disease than Whites. The 
existing data indicate that, though more Hispanics smoke cigarettes, 
fewer are heavy smokers (53,54). There are some indications, however, 
that there is heavier smoking among Hispanic youth compared to White 
and Black youth. 

The evidence on prevalence of smoking, knowledge about the risks 
of smoking, and the frequency of practice of leisure-time exercise 
suggests potentially different risks for Mexican Americans compared 
to non-Hispanic Whites. Those Mexican Americans with lowest SES and 
level of acculturation have significantly worse CVD risk factor 
profiles than those in higher SES groups (53,54). Mexican American 
women appear to improve their risk factor profile more as a result of 
increased acculturation and social mobility than do men. The limited 
amount of comparable data on other Hispanic groups precludes any 
generalization to these other groups. The relative paucity of data 
on Puerto Ricans, Cubans, and other Hispanics precludes any 
conclusions about whether health behaviors could account for any 
differences in cardiovascular disease risk between these groups and 
non-Hispanic Whites. 

Asian/Pacific Islanders 

Cardiovascular Disease 

Heart disease is the leading cause of death for all Asian/Pacific 
Islander American groups (59). However, Asians appear to be at lower 
risk of mortality from most cardiovascular diseases than other 
minorities and Whites, with the possible exception of stroke. Asian 
women appear to be at lower risk than men across all groups. Koreans, 
Filipinos, and Chinese appear to be at lower CVD risk than Japanese. 
The overall higher SES of Asians as a group may partially account for 
their more favorable cardiovascular status. 



115 



Stroke 

National data suggest stroke mortality rates in Asians are 
generally similar to those in Whites as shown in Figure 9 (60), with 
stroke as the third leading cause of death. Recent age-adjusted data 
for Asian subgroups indicate that Japanese men stand out from most 
other ethnic/gender groups, including Whites, in having very high 
stroke mortality rates (59). 

Hypertension and Smoking 

Though hypertension may not be as significant a public health 
problem among Japanese and Chinese as among Whites, Blacks, and 
Hispanics , it is a significant problem among Filipinos (61). Although 
the proportion of Filipinos receiving treatment for their hypertension 
is comparable to or greater than that of their White cohorts, fewer 
have achieved blood pressure control. Fewer Filipino women than men 
had their blood pressure under control - the reverse of the gender 
trends for all of the other ethnic groups studied. Filipinos, like 
their fellow Asians (at least those in California), do not show 
evidence of an excess prevalence of smoking compared to Whites (62) . 

Other Cardiovascular Risk Factors 

Existing morbidity data suggest that the standard risk factors 
for CHD are significantly less prevalent among Japanese on the 
mainland, in Japan, and in Hawaii than in White men in the U.S. 
Patterns of associations similar to those in Whites are found between 
the major risk factors and fatal and nonfatal CHD, nonfatal MI, and 
acute coronary insufficiency (63,64). For the Japanese, as for 
Whites, high blood pressure, cigarette smoking, and cholesterol are 
important risk factors for CVD. Overall, Japanese men typically have 
lower total cholesterol levels than White men. The limited data 
available on cardiovascular disease risk factors among Chinese 
Americans indicate that they tend to have lower levels of the major 
CHD risk factors (65). However, Chinese men over 50 years of age may 
have a greater prevalence of smokers (who smoke fewer cigarettes per 
day) and of elevated blood pressure than White men. 

The available data suggest that cardiovascular diseases are less 
prevalent among Asian groups and that perhaps part of this favorable 
mortality differential can be attributed to a more generally salutary 
risk factor profile. However, there is enough of a difference in CHD 
mortality and/or risk status among the various Asian groups and the 
data are so limited that this generally favorable picture cannot be 
assumed to hold true for all groups. 



116 



Native Americans 

Coronary Heart Disease 

Heart disease is a significant contributor to all-cause mortality 
in Native Americans but is proportionately less of a contributor than 
in the general population. If death rates from noncardiovascular 
causes such as automobile accidents and alcoholism can be reduced in 
the future, it is possible that heart disease may increase in Native 
Americans. Currently, under age 35 years, heart disease mortality for 
Native Americans is approximately twice as high as for all other 
Americans . 

Cardiovascular Risk Factors 

Hypertension appears to be an important health problem for Native 
Americans, although apparently less so than for the White population 
(3) . Serum cholesterol levels in some American Indian tribes are 
lower than those in the general population, but the relationship of 
these lower levels to the incidence of CVD is not clear. It appears 
that both obesity and diabetes are major public health concerns in 
Native Americans. The Pima Indians have the highest prevalence of 
type II diabetes in the United States (66) . Although sufficient data 
are not available to draw firm conclusions about trends in cigarette 
and alcohol use, or their contribution to CHD, cigarette smoking 
appears to be less consistently prevalent in Native Americans in 
different geographic locations, though alcohol abuse is more 
consistently prevalent (67). Both cigarette and alcohol use 
constitute a significant health hazard for Native Americans, more so 
for men than for women. 

Social, Cultural) and Economic Aspects 

Little reseach has been conducted on the contribution of 
socioeconomic factors such as low income, high unemployment, and low 
education to cardiovascular disease mortality, morbidity, and risk 
status in Native Americans. 

Although some socioeconomic factors may contribute to an 
unfavorable risk profile, other sociocultural factors may operate to 
confer some protection against coronary heart disease. Many Native 
American tribes maintain low cholesterol diets, engage in strenuous 
physical activity as part of their daily lives, and have less 
time-pressure and have lifestyles that display limited interpersonal 
competition (52) . Recent increases in urbanization, in smoking, in 
the fat content of diets, and in other behavioral risk factors 
associated with increased westernization in Native American youth in 
several tribes suggest the possible beginning of increased coronary 
heart disease risk in the population. 



117 



OPPORTUNITIES FOR PROGRESS 

Interventions proposed by the Subcommittee follow: 

Risk Reduction Interventions to Promote Cardiovascular Health 

There is evidence to justify health promotion interventions 
directed toward minority groups that would promote dietary patterns 
that would lower or maintain low blood cholesterol, would reduce or 
eliminate cigarette use, would encourage an active lifestyle, and 
would moderate and maintain normal body weight and blood pressure. 
Effective behavior modification strategies for the treatment of CVD 
and these CVD risk factors need to be developed and validated in 
minority populations. Successful techniques should be taught to both 
the deliverers and the receivers of health care. For example, studies 
are needed of 

• The determinants of cigarette smoking and alcohol use, 
cessation, and cessation maintenance in all minorities. 

• The relationship of obesity, especially in Black females during 
and after adolescence, to lipoproteins and other factors. 

• Socioeconomic status as a risk factor for CHD, hypertension, 
stroke, and hypertension-related end-stage renal disease in all 
minority groups. 

• The factors responsible for confering some degree of protection 
with regard to CHD mortality in Asian/Pacific Islanders, 
despite a relatively high-risk profile. 

• The impact of diabetes and obesity in Native Americans and 
Hispanics . 



Effective Cardiovascular Health Education 

Effective strategies for cardiovascular health education among 
specific minority groups should be developed. Procedures should be 
indentified to facilitate the adoption of specific interventions for 
cardiovascular risk factors such as high blood cholesterol levels and 
cigarette smoking in the general minority populations as well as in 
high-risk subgroups. The model of the National High Blood Pressure 
Education Program could be adopted and modified for other risk factors 
for a variety of communities. Care must be taken to consider the 
different cultural values and attitudes towards CHD and certain risk 
factors for CHD, such as obesity, chest pain, and particular 
health-seeking behaviors. The publication and updating of a list of 
DHHS health promotion and disease prevention materials, including 



118 



patient education materials, especially directed toward specific 
minority groups, would be of value to practicing physicians and other 
health care providers . 

Hypertension Prevention and Control 

Continued efforts at education, prevention, treatment and control 
of the hypertension-related diseases, for example, stroke and 
end-stage renal disease, especially in Blacks, are needed. In 
addition: 

• The long-term efficacy and safety of antihypertensive 
medications prescribed to minorities (particularly to Blacks) 
need to be examined. Do the metabolic, hemodynamic, and side 
effects of treatments and their impact on CHD differ among 
minorities and Whites? 

• Compliance/noncompliance to antihypertensive medication 
regimens needs to be studied. Why do Filipino women have 
poorer blood pressure control than Filipino men? This is in 
contrast to other ethnic minority groups in the United States 
in which women generally have better blood pressure control 
than men. 

• Investigation of the links between dietary potassium, sodium, 
calcium and, possibly, other dietary elements and hypertension 
in Blacks and other minorities is needed. 

Delivery of Medical Care 

In addition to genetic, environmental, and behavioral factors, 
appropriate medical care is a major determinant of morbidity and 
mortality due to cardiovascular disease. Under optimal medical care 
conditions, for example, a patient with essential hypertension can 
achieve blood pressure control and reduce the risk of cardiovascular 
sequelae. However, with variations in physician behavior and patient 
care-seeking behavior, optimal medical care circumstances are 
difficult to achieve for large population groups, and are equally if 
not more difficult to achieve for most minority populations. 
Simultaneous attention to all the elements of interaction in the 
medical care setting, including both patient and physician behavior, 
is necessary. Such research is needed to understand the dynamics of 
medical care available to Blacks, Hispanics, Asian/Pacific Islanders, 
and Native Americans because appropriate diagnosis, treatment, and 
follow-up predispose for a favorable outcome. For example, studies 
are needed of beliefs, awareness status, and prehospital behavior 
which might delay appropriate diagnosis and treatment for individuals 
with symptoms of coronary heart disease in minority communities. 
Investigation is needed on how specific patterns of risk factors in 
minorities influence treatment decisions. Techniques are needed that 
will encourage earlier diagnosis, full use of all diagnostic 



119 



procedures, and earlier treatment interventions so that minorities 
enter the delivery system well before an advanced disease state has 
developed. 

Minority Population Studies of Cardiovascular Diseases 

Population-based, prospective, observational studies of coronary 
heart disease (similar to the Framingham study) are needed for the 
minority populations. A key component of this research would be the 
validation in minorities of the major established and/or suspected 
biological and psychosocial risk factors for CVD that have been 
identified for the White American population. For example, among the 
many Hispanic subgroups, Puerto Ricans residing in the United States 
and Cubans particularly warrant such research. Another key element of 
such research would be the surveillance of the offspring of indexed 
cases so as to provide crucial information on trends for risk and for 
disease as well as elucidating familial contribution to CVD incidence 
and process. Further studies on potential differences in sudden death 
rates between Blacks and Whites, by age and gender, are needed. There 
is a need to monitor CVD events that occur in the community, such as 
sudden death; hospital admissions and discharges of patients diagnosed 
to have CVD; and emergency room visits for chest pains and related 
complaints . 



Direct Federal Government Activities 

DHHS should serve as a catalyst to bring together, on a 
continuing basis, concerned groups to focus on specific issues, such 
as: cholesterol, cigarette smoking, and worksite health. These 
groups should give specific attention to minority issues. The 
National High Blood Pressure Education Program could serve as a model 
for this activity. 

Meetings should be initiated between DHHS program units and 
program representatives from other Federal departments to address 
health problems of mutual interest relating to cardiovascular disease 
and its prevention. Specifically, information exchange and 
coordination of smoking cessation arid health promotion programs should 
be strengthened. The Departments of Defense and Education, for 
example, could join with the several DHHS programs in these areas in 
seeking to accomplish this. 

Employees of the Federal Government should be urged to explore 
health care plans that offer preventive health services. 

More Minority Professionals for Health Care and Research 

Development of innovative mechanisms to attract minorities into 
the health care field and into health research needs to be undertaken 
with direct and continuing input from leaders in the minority health 
professions . 



120 



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127 



SUBCOMMITTEE ON CHEMICAL DEPENDENCY 

EXECUTIVE SUMMARY 

Introduction 

This report reviews the role that chemical dependency plays in 
contributing to the health disparity between Blacks, Hispanics, 
Asian/Pacific Islanders, and Native Americans and the nonminority 
population. Using excess mortality rates in minority populations due 
to cirrhosis, cancer, and unintentional injuries as a basis, the 
Subcommittee chose to include alcohol abuse, illicit drug abuse, and 
cigarette smoking as elements of chemical dependency. The 
Subcommittee did not include the abuse or misuse of licit drugs. 
Although these substances may contribute to the health disparity, few 
data are available on which to base an analysis. 

The 19 79 Surgeon General's report. Healthy People , indicates that 
alcohol misuse is a factor in more than 10 percent of all deaths and 
may be higher among minorities (1). Tobacco use is a factor in more 
than 16 percent of all deaths; nearly 90 percent of all lung cancers 
are caused by cigarette smoking (2). No similar statistics are 
available for illicit drug abuse. 

Because data on the prevalence of chemical dependency for the 
minority population are limited, it is difficult to know the extent of 
the problem among minorities and the resultant impact on health 
status. Excess deaths among minorities due to cirrhosis, heart 
disease, unintentional injuries, homicide, and cancers of the mouth, 
larynx, tongue, esophagus, and lung provide insight into the problems 
of chemical dependency. Figure 10 illustrates the average annual 
death rates by race for chronic liver disease and cirrhosis, one of 
the indicators of the problem of alcohol abuse. 

Alcohol 

Alcoholism and alcohol-related problems are complex and involve 
a wide range of medical, social, and legal problems that impact on 
different populations at risk in different ways. All persons of a 
particular group are not at equal risk for alcohol-related adverse 
health outcomes. However, an inadequate body of research exists on 
the impact of alcohol and alcohol-related problems on minority health 
status. The majority of national studies, to date, were designed to 
elicit baseline data on the general population. As a result, minority 
samples from these surveys generally are too small to draw definitive 
statements and conclusions about alcohol use and the nature and 
extent of alcohol-related problems among minorities. 



129 





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Blacks 

Few studies exist on the subject of alcohol and Blacks; however, 
there is evidence that alcohol abuse has a major impact on the health 
of Blacks. Using cirrhosis deaths as an indicator of high alcohol 
use, cirrhosis mortality rates have declined consistently among all 
race-sex groups in the United States since 1973, but they are still 
disproportionately high among Black Americans (3). Overall, the 
cirrhosis mortality rate for Blacks is nearly twice that of 
nonminorities (4). In addition, Blacks suffer disproportionately from 
the health consequenes of alcoholism, including esophageal cancer. 

A national survey conducted in the 1960s indicated that Black and 
White men differed little in their drinking patterns, but that Black 
women had a higher proportion of abstainers and of heavier drinkers 
than Whites (51 percent versus 39 percent and 11 percent versus 7 
percent, respectively) (5). The quantity and frequency of alcohol 
consumption for Black and White males are comparable when social class 
is controlled (6) . A 1979 national survey of American drinking 
practices found that both Black males and females were more likely to 
classify themselves as abstainers than Whites (30 percent versus 25 
percent for males and 49 percent versus 39 percent for females, 
respectively) (7). Overall, Black drinking patterns are similar to 
those reported in the general population, with rates varying greatly 
along geographic, sex, and religious dimensions. 

Blacks appear to be at disproportionately high risk for certain 
alcohol-related health problems. National Cancer Institute data 
indicate that between 1979-1981, the incidence rate of esophageal 
cancer for Black males, aged 35-44 years, was ten times that of Whites. 
Alcohol consumption is believed to be a primary etiologic agent in the 
development of this cancer. Fetal alcohol syndrome (FAS) is a 
health consequence associated with heavy alcohol use in pregnant women 
(8). Current data on FAS are inconclusive for Black women, and further 
investigation is required to define the relationship between alcohol, 
the prevalence of FAS, and related effects. 

Data from national surveys show that Black youths, ages 14-17, 
drink less than White youths, have consistently higher abstention 
rates, and have consistently lower heavy drinking rates and similarly 
lower alcohol-related social consequences than their White 
counterparts (9) . Black males begin to report high rates of heavy 
drinking and social problems due to drinking after the age of 30, 
compared with White males where heavy and problem drinking is 
concentrated in the age group of 18 to 25 years. 

Hispanics 

Studies of Hispanic drinking practices and consequences are less 
available and not as informative as those for Blacks. Mortality 
statistics for the United States do not identify Hispanics separately, 



131 



and, until 1976, most other common measures of alcohol-related problems 
such as arrest and hospital discharge rates did not provide a 
Hispanic identifier. Although some information is available from 
regional surveys, these data are limited to specific subpopulations 
such as Mexican Americans. Nonetheless, there is some indication that 
Hispanics , particularly young males, suffer disproportionate health 
consequences as a result of their use of alcohol. 

Deaths from cirrhosis of the liver are a general indicator of 
high alcohol use within a given population. Several studies suggest 
that death rates from cirrhosis among Mexican Americans and Puerto 
Ricans may be higher than among the general population. While there 
is some indication that Hispanics are overrepresented in the mortality 
statistics for alcohol-related causes, these data stem mainly from 
studies in a few cities or counties in the Southwest. Little is known 
about the health consequences of alcohol use among Hispanics in the 
rest of the United States. 

The 1979 National Institute on Alcohol Abuse and Alcoholism 
National Survey indicates that based on self-reported data, Hispanic 
American males ages 18 and older have higher levels of heavy drinking 
and higher rates of alcohol-related problems than do nonminorities 
(10). Hispanic females, however, reported being either abstainers or 
light drinkers. The most recent study on drinking patterns suggests 
that young Hispanic males, ages 18 to 29 years, tend to drink more 
heavily than either Black or White youths and young adults (34 
percent, 17 percent, and 29 percent, respectively) (11). 

Native Americans 

The Indian Health Service reports that five of the top ten causes 
of death among Indians are directly related to alcohol: accidents (21 
percent), cirrhosis of the liver (6 percent), alcoholism (3.2 
percent), suicide (2.9 percent), and homicide (2 percent). National 
mortality statistics indicate that these five causes account for 35 
percent of all deaths among Native Americans (12). A recent report 
based on age-adjusted mortality rates found that the mortality rate 
from alcohol-related causes of death was more than three times higher 
among Native Americans than that of other groups. Among Alaska 
Natives, alcoholism and alcohol-related problems are a major health 
problem. Alaska Natives, who comprise 17 percent of Alaska's 
population, account for 60 percent of the alcoholism deaths in that 
State (13). 

Unintentional injuries account for an estimated 21 percent of all 

deaths in the Native American population and are the leading cause of 

mortality. The Indian Health Service estimates that 75 percent of all 
accidental deaths among Indians are alcohol-related (12). 

The fourth-ranked cause of death among Native Americans, 
cirrhosis of the liver, accounts for nearly 6 percent of total deaths, 
compared with 1.7 percent of the total deaths for the Nation. 



132 



According to one study, cirrhosis mortality rates for Native 
Americans are higher than rates for Black or White adults, and the 
highest rates for Native Americans occur at younger ages. Examination 
of the sex-specific data reveals that Native American women have much 
higher cirrhosis mortality rates than either Black or White women at 
all age levels (12). 

The diagnosis of alcoholism accounts for an estimated 3.2 percent 
of all Native American deaths, which is approximately four times the 
rate for the Nation. Researchers suggest that this diagnosis might be 
ranked even higher if all deaths from alcoholism were accurately 
reported. 

Suicide accounts for 2.9 percent of all deaths within the Native 
American population, or twice the national percentage. It is 
estimated that 80 percent of all deaths by suicide within the Native 
American community are alcohol-related (12). 

The tenth-ranked cause of death in Native American communities is 
homicide, which accounts for an estimated two percent of total deaths. 
The Indian Health Service reports that 90 percent of homicides com- 
mitted within Native American communities occur while either the per- 
petrator, the victim, or both are under the influence of alcohol (12). 

Another medical consequence of alcohol abuse for which some 
Native Americans appear to be at higher risk is fetal alcohol 
syndrome/ fetal alcohol effects (FAS/FAE), although the risks appear 
variable depending upon the tribal group. An epidemiological study of 
FAS among Native Americans of the Southwest concluded that the 
incidence and patterns of recurrence of FAS among the three groups 
studied (Plains Indians, Navajo, and Pueblo) showed consistent dif- 
ferences, ranging from a high of 10.3 per 1,000 live births for Plains 
Indians, to 1.3 per 1,000 live births in the Navajo population (14). 

Alcohol use varies tremendously from one tribe to the next--some 
tribes have proportionately fewer drinking adults than the U.S. 
population as a whole (30 percent compared to 67 percent) whereas 
other tribes have more drinkers (69 to 80 percent) --with the 
prevalence of alcohol-related problems also being highly variable 
(15). The ability to define subpopulations at risk is important in 
terms of preventive measures. Clearly, the health consequences of 
alcohol use and abuse for Native Americans are a major public health 
concern that must be addressed. 

Asian/Pacific Islanders 

The impression that Asian/Pacific Islanders do not consume as much 
alcohol as the general population is generally supported by research 
studies. However, because of the wide variations in drinking among 
the different Asian nationalities, it is difficult to arrive at 



133 



generalizations without specifying country of origin and understanding 
some of the historical-cultural factors that contribute to the 
differences among Asian subpopulations with regard to the use of 
alcohol . 

There is evidence of wide variation among Asian/Pacific Islander 
groups in terms of problem behavior related to alcohol consumption, 
although very little research exists in this area (16). Native 
Hawaiians, however, appear to be at increased risk for excess 
mortality from alcohol-related motor vehicle accidents (17). 

Research on the so-called "flushing reaction" shows that 
approximately 50 percent of persons of Asian background metabolize 
alcohol much more quickly than do Caucasians, causing a "flushing 
reflex" and a high degree of discomfort, which may provide some 
protection against heavy drinking and related problems. However, the 
relationship between this sensitivity and the use of alcohol needs 
further exploration. 

Drug Abuse 

National surveys of drug and alcohol abuse have been designed to 
focus on the general household population. Consequently, there are no 
national data on race- or ethnic-specific rates for drug abuse or the 
health consequences of drug abuse. Estimates of the prevalence must 
be viewed conservatively, since certain potentially high-risk 
subgroups such as persons with no fixed residence or institutionalized 
populations (e.g., college students living in dormitories) are not 
included in the sample. Data on admissions to treatment centers, 
emergency room visits, and medical examiner cases among minorities 
provide some data on the consequences among minority populations. 

Another problem in obtaining data on minorities is that Blacks, 
Hispanics , Native Americans, and Asian/Pacific Islanders are sampled 
proportionately to their numbers in the general population. The 
actual sample size for minorities is substantially smaller than that 
for Whites (1,093 Blacks sampled in the 1982 National Household Survey 
on Drug Abuse (NHSDA) and 4,520 Whites). Blacks and Hispanics are 
being oversampled in the 1985 NHSDA in an effort to provide more 
reliable estimates of drug abuse prevalence in minority populations. 

Despite these data limitations, the studies that have been done 
suggest that drug abuse-related morbidity and mortality in Blacks, 
Hispanics, and Native Americans are greater than for the White 
population. Data on the Asian population do not indicate similar 
excess mortality. 

Data from the 1982 NHSDA indicate that the prevalence of reported 
drug use within the household population is generally higher in urban 
areas than in suburban or rural areas (18). Thus, to the extent that 



134 



minorities are more likely to reside in inner-city areas, they may be 
at greater risk of drug abuse and, ultimately, the negative social and 
health consequences associated with drug abuse. 

The overall prevalence of drug abuse in the general household 
population, ages 12 and older, is about the same for minorities as it 
is for Whites (18). Minorities were more likely than Whites to report 
marijuana as their only form of illicit drug use. Among both 
minorities and Whites, the highest levels of current drug use were 
reported by young adult males, ages 18 to 25 years. Among young adult 
White men, 21 percent reported current use of marijuana only (19). 
Thirty-six percent of young adult minority men reported current use of 
marijuana only. 

Another important aspect of marijuana use among minorities is 
that unlike the pattern for young adult Whites, a decreasing trend in 
use has not been observed among minority young adults, ages 18 to 25 
years. The decreasing trend of marijuana use among White youths, ages 
12 to 17 years, however, does appear to be paralleled by a decreasing 
trend among minority youths in that same age group (19). 

The health consequences of drug abuse may be greater for 
minorities than for nonminorities as a result of the route used to 
administer the drugs. To the extent that minorities are more involved 
in the intravenous use of drugs, they are at increased risk of 
potentially fatal infections from hepatitis B virus, bacterial 
endocarditis, and acquired immune-deficiency syndrome (AIDS) (20-22). 

A few follow-up studies of narcotic addicts hospitalized and 
treated for their drug problems suggested that they experienced 
greater-than-expected rates of accidents, suicides, homicides, and 
deaths due to overdose (23) . Data specific to minorities are not yet 
available to determine if traffic accidents are associated with 
illicit drug use (24). Additional studies of the health consequences 
of drug abuse that report data with racial and ethnicity identifiers 
are discussed in the minority-specific sections of this report. 

Blacks 

Data from the 1980 census indicate that Blacks constitute 11.5 
percent of our population; however, they constitute 22.5 percent of 
the population of the inner cities (25). As such, they may be at 
greater risk of drug abuse and its consequences. Evidence of higher 
rates of drug use in populations having no fixed residence is provided 
by a 1983 study of drug use among tenants of single-room occupancy 
hotels (SRO) in New York City. Results suggest that Blacks have 
higher rates of drug use than Whites for marijuana, cocaine, heroin, 
and illicit methadone. Further analysis of a sample of Blacks matched 
for age and sex from the household population and the SRO 
population indicated that SRO tenants were three times as likely to 
have used drugs recently as were the New York City household 
residents (26) . 



135 



Data obtained from the 1982 National Drug and Alcoholism 
Treatment Utilization Survey (NDATUS) , a national survey of public and 
private treatment units, suggest that Blacks are three times more 
likely to be in treatment for a drug abuse-related problem than are 
Whites (27). 

Data from the Drug Abuse Warning Network (DAWN) --gathered from 
treatment programs, emergency rooms, and medical examiner cases-- 
indicate that minorities are more likely than nonminorities to be 
involved with more dangerous drugs and with more dangerous 
combinations of drugs. (Generalizations to the total population 
cannot be made from the DAWN data, which are based on 27 metropolitan 
areas and a panel of emergency rooms outside these metropolitan 
areas.) For example, 31 percent of Black treatment clients reported a 
primary problem with heroin, cocaine, or PCP, a figure three times 
that reported by White clients. They were also more likely to report 
use of other substances, with inhalants being the drug most commonly 
included (19). Heroin use is difficult to measure in the household 
survey because it is a relatively rare event; it is more likely to 
involve the nonsampled population, and it is more likely to be 
underreported . 

Recent medical examiner data reported to DAWN show increases in 
positive toxicology for cocaine with or without other drugs for all 
races over the past three years. Between 1982 and 1984, 
cocaine-related deaths among Blacks tripled (51 to 177), while they 
doubled among Whites (149 to 312) (28). Heroin trends have been 
relatively stable over the same time period. The percentage of 
PCP-related deaths alone or in combination with other drugs 
increased in Blacks from 50 percent in 1983 to 58 percent in 
1984 (personal communication. National Institute on Drug Abuse, 1985). 

DAWN data for 1984, taken from emergency room episodes only, 
showed that, of 96,047 cases, Blacks were somewhat more likely than 
were Whites to have used more dangerous routes of cocaine 
administration--by injection (used by 49 percent of Blacks versus 40 
percent of Whites) and by smoking or freebasing (9 percent of Blacks 
versus 3 percent of Whites) . Because these data are not based on 
statistical sampling procedures, generalizations to the total 
population cannot be made (19) . 

Some data are available to suggest a relationship between drug 
abuse and homicide. A study conducted by the New York City Police 
Department in 1981 and 1982 found that 53.1 percent and 46.4 percent, 
respectively, of drug-related homicides involved Black victims (29). 

Hispanics 

Data from the 1980 census indicate that Hispanics constitute 6.4 
percent of our population; however, they constitute 10.8 percent of 
the population of the inner cities (25). As such, they may be at a 



136 



somewhat greater risk of drug abuse and its consequences. Results 
from the 1983 SRO study of drug abuse in New York City suggest that 
Hispanics have higher rates of drug use than non-Hispanic Whites for 
marijuana, cocaine, heroin, and illicit methadone (26). 

Multiple drug use is a problem for all minorities. Data from 
hospital emergency room cases and from drug abuse treatment programs 
indicate that Hispanics were more likely than Whites to report a 
primary problem with heroin, cocaine, or PCP. In addition, inhalants 
were the most commonly reported category of other drugs used. A 
dramatic increase in reports of positive toxicology for cocaine was 
found among the Hispanic population. Between 1982 and 1984, 
cocaine-related deaths among Hispanics tripled (16 to 49), while they 
doubled among Whites--from 149 to 312 (19). 

Recently, it has been suggested that prevalence of inhalant use 
by Hispanic youths is high. Although this cannot be supported by 
household and high-school population surveys, a 1979 study of 
Mexican American children and adolescents in Los Angeles barrios found 
prevalence of inhalants 14 times that of the general population (30) . 

The 1982 NDATUS suggested that Hispanics are 2.7 times more 
likely to be in treatment for a drug abuse-related problem than are 
Whites (27). 

The 1984 DAWN data indicate that of those treated for 
drug-related emergency room episodes, 42 percent of Hispanics as 
compared with 40 percent of Whites administer cocaine by injection; 6 
percent of Hispanics as compared with 3 percent of Whites administer 
cocaine by smoking or freebasing. Both are more dangerous routes of 
administration than the intranasal route and lead to more frequent use 
of the drug (19). Recently, intravenous use of a "designer" drug, 
meperidine-analog-synthesis (MPTP) , has been associated with early 
onset of chronic Parkinsons disease symptoms in drug addicts (31) . 
While cases are still being identified, a large proportion of the 
initial cases were Hispanic (personal communication, Paul Jarbe) . 

A 1981-82 New York City Police Department study of drug-related 
homicides found that 34.2 percent involved Hispanic victims. In 1982, 
the percentage of Hispanic victims increased to 41.8 (29). Reports 
based on the New York City medical examiner cases from 1967 to 1970 
indicate an overrepresentation of Hispanics among narcotic addiction 
deaths. An investigation of 927 deaths among New York City narcotic 
addicts in 1971 found that 16 percent were Puerto Rican. 

Native Americans 

Data obtained from the 1982 NDATUS suggest that Native 
Americans are twice as likely to be in treatment for a drug 
abuse-related problem than are Whites (27). 



137 



Treatment data were collected nationally in 1983 on a voluntary- 
basis through the Client Oriented Data Acquisition Process (CODAP) , 
(based on 23 states, Washington, D.C., and territories; California 
represented 46 percent of treatment admissions). The proportion of 
1983 CODAP client admissions, excluding alcohol, was 0.6 percent for 
American Indians/Alaska Natives. Although the representation of 
Native Americans in the CODAP service area is unknown, this rate of 
admissions is one and a half times the representation of Native 
Americans in the U.S. population. CODAP also indicated that American 
Indian clients were more likely than White clients to report a primary 
problem with heroin, marijuana, or PCP. Native Americans also were 
more likely to report the use of "other" drugs than White clients. 
The most common type of the "other" drugs category reported was 
inhalants (19). 

Few studies and surveys of drug abuse have focused on minority 
subgroups of the population, however, one survey of Native American 
youth, (7th through 12th grade in Indian reservation schools) has been 
conducted annually since 1975. Results from this survey for 1980-81, 
on the lifetime prevalence of substance use for Native American high 
school seniors, show that for 10 of 12 substance categories, Native 
Americans have higher lifetime prevalence rates of substance use 
than high-school seniors nationally. "Ever-use" of marijuana (88 
percent) and inhalants (34.4 percent) by Native American seniors, in 
particular, far exceeds that for national high-school seniors, which 
is 59.5 percent and 12.3 percent respectively (32). Although lifetime 
prevalence rates provide an indication of exposure, figures on 
frequency of use for a given time period provide a better indication 
of consequences and/or problem use. When frequency of substance use 
for Native American youth (grades 7-12) is compared with a sample of 
similarly aged non-Native American urban youth, a striking difference 
is evident for marijuana. In 1980-81, 13.4 percent of Native American 
youth reported daily use of marijuana in the 2 months before the 
survey as compared with 2.6 percent of the non-Native American urban 
youth (32). 

Asian/Pacific Islanders 

There is a paucity of data on prevalence of drug abuse among 
Asian/Pacific Islanders. The little information that is known 
suggests that the incidence of drug abuse is lower than that of the 
White population; however, existing data are insufficient to draw any 
definitive conclusions. 

The 1983 treatment data collected through CODAP reported that 
only 0.8 percent of all the clients admitted were Asian/Pacific 
Islanders; thus, this group appears to be underrepresented in the 
treatment population (19). The proportion of the Asian/Pacific 
Islander population in the United States is 1.6 percent. 



138 



A 1971 New York City investigation of 927 deaths among narcotic 
addicts, during a 9-nionth period, found only 2 percent of the deaths 
were Asian/Pacific Islander, although, representatively, a much larger 
Asian American population resides in that area. 

Smoking 

Cigarette smoking is the chief preventable cause of death in the 
United States. Cigarette smoking is a causal factor for coronary 
heart disease and arteriosclerotic peripheral vascular disease; cancer 
of the lung, larynx, oral cavity and esophagus; and chronic bronchitis 
and emphezema. It is also associated with cancer of the urinary 
tract, bladder, pancreas, and kidney, and with ulcer disease and low 
birthweight (2). 

Differences exist between the smoking behavior of minorities and 
nonminorities , and the incidence and gravity of cigarette-related 
diseases varies. The most important of these are differences in the 
smoking behavior of nonminority and minority males, especially for 
Blacks and Hispanics (33) . 

Blacks 

The National Health Interview Surveys (NHIS), conducted by the 
National Center for Health Statistics (NCHS) , are the major sources of 
data on the smoking behavior of the U.S. population. Data from NHIS, 
for the period between 1965 and 1980, show a steady decline in the 
prevalence of smoking, a decline evident for both Whites and Blacks. 
The prevalence of Black male smokers declined from 59.6 percent in 
1965 to 44.9 percent in 1980. Among White males, the prevalence of 
smokers declined from 51.3 percent in 1965 to 37.1 percent in 
1980 (34). 

Substantial differences exist between cigarette smoking patterns 
of Blacks and Whites, yet the way in which these differences affect 
the health outcome of Blacks versus Whites is unclear. Differences 
have been observed in total smoke exposure as measured by age of 
initiation, number of cigarettes smoked per day, and tar and nicotine 
content of cigarettes smoked. 

The prevalence of cigarette smoking among Black males has 
consistently exceeded that of White males; however, only small 
differences in prevalence exist between White and Black females. 
Significant differences do exist, however, between Black and White 
females with respect to number of cigarettes smoked per day. Black 
females have a higher prevalence of "never-smokers" than do White 
females at every income level above $5,000. Differences observed 
between Black and White males are not explained by occupational, 
educational, or income differences. However, the highest prevalence 
of White males who have never smoked was in the lowest income level 
(below $3,000) while the lowest prevalence of never smokers among 
Black males was in the lowest income level. 



139 



NHIS data on numbers of cigarettes smoked indicate that Whites 
are heavier smokers than Blacks. Among White males, 35.9 percent were 
heavy smokers as compared with 11.9 percent among Black male smokers. 
Similarly, White female smokers smoked more cigarettes per day than 
did Black female smokers. For White females, 23.8 percent smoked more 
than 25 cigarettes a day versus 7.5 percent for Black females (35). 
In contrast, both Black males and females smoked cigarettes of higher 
tar content than did either White males or White females . Although 
the percentage of Blacks who ever started smoking is lower than the 
percentage of Whites who ever started smoking, once started. Blacks 
are less likely to attempt to quit or to quit successfully. 

The effect these differences in smoking patterns have on 
mortality and morbidity patterns exhibited by Blacks and Whites is 
unknown; however, it is clear that nearly 90 percent of all lung 
cancers are caused by cigarette smoking and that smoking-related 
cancers seem to be particularly high among Blacks. Blacks have higher 
incidence rates for the tobacco-related cancers of the lung, 
esophagus, pancreas, and stomach. (For more discussion, refer to the 
Summary Report of the Task Force Subcommittee on Cancer.) Smoking 
appears to increase the risk of cardiovascular disease mortality in 
both Blacks and Whites. It is not known, however, how differences in 
smoking patterns between Blacks and Whites affect differences in 
cardiovascular disease for these groups. (Further information is 
contained in the Summary Report of the Task Force Subcommittee on 
Cardiovascular and Cerebrovascular Disease.) 

Hispanics 

Lung and esophageal cancer morbidity and mortality rates, known 
to be related to smoking, are lower for Hispanics than for 
non-Hispanic Whites and Blacks. An exception to this has been 
reported for New Mexico Hispanic females, among whom the incidence of 
esophageal cancer is 20 percent higher than non-Hispanic Whites . 
Studies suggest a link between the development of esophageal cancer 
and smoking and alcohol consumption, with the latter two having a 
synergistic effect (36). 

It is not adequate only to consider smoking-related cancer data 
as indicators of future risk for any group; current smoking behavior 
patterns must also be considered. Overall prevalence rates of smoking 
among Hispanics are relatively low due to the consistently lower rates 
of smoking observed among Hispanic females; however, prevalence rates 
among Hispanic males are quite high. Recent surveys of smoking 
behavior in California, Texas, and New Mexico indicate that Hispanic 
males appear to be smoking as frequently as their non-Hispanic White 
counterparts, although their consumption levels appear to be lower (37) 
Data from the 1980 NHIS indicate that 40.9 percent of Hispanic 
males and 22.9 percent of Hispanic females were current smokers as 
compared with 38.2 and 31.4 percent of Whites, respectively (33). 



140 



Examination of data from the "Know Your Body" program showed that 
male and female Hispanic adolescents exceeded both male and female 
White and Black adolescents in self-reported current cigarette use. 
Findings from that survey and others suggest that, as cigarette use 
increases among Hispanics, incidence rates for tobacco-related cancers 
may increase in Hispanics, and that prevention efforts aimed at this 
group are needed in the future. 

Native Americans 

Limited data are available from which to examine smoking behavior 
and its health consequences in the Native American population. 
Overall, Native Americans have smoking-related, lung cancer rates 
lower than those of Whites; however, the relative frequency of lung 
cancer differs among tribes. For example, among Oklahoma Indians, 
where the lung cancer standardized mortality ratio is higher than in 
other tribes, both cigarette smoking and lung cancer mortality more 
closely mirror the national average. In contrast. Native Americans of 
the Southwest, who seldom smoke, have low rates of smoking-related 
lung cancer (2) . Environmental and cultural factors such as urban, 
rural, and reservation living conditions may play a role in this 
discrepancy. 

Data do exist for Native American high-school seniors and the 
prevalence of smoking among this population. Based on a study that 
compared the lifetime prevalence of substance use between 1980-81 for 
Native American high-school seniors and national high-school seniors. 
Native American high-school seniors exhibited a prevalence rate for 
cigarette smoking of 72.3 percent, compared with 71.0 percent for high 
school seniors in the Nation (19). Although not significantly 
different from the rate reported nationally, the smoking prevalence of 
Native American youth needs to be more closely monitored, as one 
indicator of future risk for smoking-related cancers. 

Asian/Pacific Islanders 

The prevalence of smoking among Asian/Pacific Islanders is 
unknown due to the paucity of data. Certain subgroups within the 
Asian population do exhibit excess incidence and mortality for some 
smoking-related cancers. For example, Hawaiians have excess mortality 
for cancer of the lung (refer to the Subcommittee Report on Cancer) . 
Also, the incidence of esophageal cancer is 2.5 times higher for 
Japanese males than White males; 1.8 times higher for Chinese males 
than White males; and 1.6 times higher for Chinese females than for 
White females (2). Major risk factors for esophageal cancer are 
smoking and alcohol consumption, with the use of both having a 
synergistic affect. Finally, excess risk for pancreatic cancer has 
been found among cigarette smokers; pancreatic cancer incidence is 
about 20 percent higher among Chinese females than among Whites, and 
an upward trend in incidence exists for Chinese of both sexes. 



141 



Although the prevalence rates of smoking for Asian/Pacific 
Islanders are unknown, it is clear that an increased incidence for 
certain smoking-related cancers exist among subgroups of the Asian 
population. 



OPPORTUNITIES FOR PROGRESS 

Interventions proposed by the Subcommittee follow: 

• Promote the initiation and/or expansion of efforts to develop 
coping skills in children and adolescents, ages 9 to 15 years, 
to delay or prevent the use of substances such as tobacco, 
drugs, and alcohol, with special emphasis on the needs of 
minorities . 

• Foster the development of peer-group instruction programs in 
school settings designed to strengthen resistance to the use of 
substances such as tobacco, drugs, or alcohol, with special 
emphasis on the needs of minorities. 

• Perform research into cirrhosis, including studying the basic 
biological mechanisms involved in the development of cirrhosis 
of the liver in Black, Native American, and Hispanic 
populations . 

• Develop programs to prevent alcohol-related unintentional death 
and injury among Blacks, Hispanics , Native Americans, and 
Native Hawaiians . Epidemiological research is needed to 
define further the subpopulations of each minority group that 
are at greatest risk so that prevention and education efforts 
as well as early intervention and treatment programs can be 
developed and targeted with greater likelihood for success. 

• Investigate the biological consequences of alcohol use in 
terms of its contribution to excess mortality among minority 
groups. The role of alcohol use in hypertension, the role of 
alcohol use in the development of some cancers in Blacks, and 
the extent to which alcohol is a factor in the adverse 
pregnancy outcomes among all minority groups, especially Black 
and Native American women, are suggested topics. 

• Determine the nature and extent of smoking among Hispanics, 
Native Americans, and Asian/Pacific Islanders so that the 
health consequences associated with smoking in these 
populations might be understood and appropriate prevention 
strategies developed. 



142 



• Study the prevalence, etiology, and consequences of drug 
abuse among Blacks, Hispanics , Native Americans, and Asian/ 
Pacific Islanders through case-control cohort, or historical 
cohort epidemiological studies utilizing culturally sensitive 
instruments . 

• Develop improved incidence and prevalence data gathering 
techniques to assess alcohol and drug abuse among all 
minority groups. 

• Develop mechanisms in concert with appropriate state and 

local entities to support specialized drug abuse prevention and 
treatment programs in rural and urban Native American/Alaska 
Native communities. 

• Encourage Blacks to enter smoking cessation programs 
and maintain cigarette abstinence. 

• Review DHHS health professionals' training programs to ensure 
the inclusion of education about alcohol and drug abuse in 
the curricula. 

• Provide assistance to appropriate organizations for health 
care professionals to ensure that education on 

alcohol and drug abuse is included in their training curricula. 
This includes training in the diagnosis and prevention of 
alcohol and drug abuse in a variety of patient populations, 
including ethnic minorities; in referring patients to appropriate 
treatment settings; and, in the provision of direct service and 
treatment that is relevant to the specific minority patient. 

• Encourage private sector organizations to train minority 
research scientists and health care providers in substance 
abuse research, diagnosis, and treatment. 



143 



REFERENCES 



1. U.S. Department of Health and Human Services. (19 79). Healthy 

people: The Surgeon General's report on health promotion 

and disease prevention (DHEW (PHS) Publication No. 79-55071). 

Washington, DC: U.S. Government Printing Office. 

2. Report of the Subcommittee on Cancer . (1985). Unpublished 

manuscript, Task Force on Black and Minority Health, DHHS . 

3. Grant, B. F., & Aiken, S. (1984, November). Reported cirrhosis 

mortality-United States. Centers for Disease Control 
Morbidity and Mortality Weekly Report , 33(46), 657-659. 

4. Williams, M. (1982). Blacks and alcoholism: Issues in the 1980s. 

In Alcohol Health and Research World (Vol. 6, No. 4). 
Bethesda, MD: National Institute on Alcohol Abuse and 
Alcoholism. 

5. Cahalan, D., Cisin, I., & Crossley, H. (1969). American 

drinking practices (Monograph No. 6). New Brunswick, 
NJ: Rutgers Center for Alcohol Studies. 

6. National Institute on Alcohol Abuse and Alcoholism. (1980, August). 

Facts in brief: Alcohol and Blacks . Rockville, MD: 
National Clearinghouse for Alcohol Information. 

7. Cahalan, D., & Room, R. (1974). Problem drinking among 

American men (Monograph No. 7). New Brunswick, NJ: Rutgers 
Center for Alcohol Studies. 

8. Herd, D. (1985). A review of drinking patterns and alcohol 

problems among U.S. Blacks . Unpublished manuscript, 
Task Force on Black and Minority Health, DHHS. 

9. Rachal, J. V. (1982). Alcohol abuse among adolescents. In 

Alcohol Consumption and Related Problems . (Alcohol and 
Health Monograph No. 1, p. 69). Rockville, MD: National 
Institute on Alcohol Abuse and Alcoholism. 

10. National Institute on Alcohol Abuse and Alcoholism. (1980, August). 

Facts in brief: Alcohol and Hispanics ■ Rockville, MD: 
National Clearinghouse for Alcohol Information. 

11. Caetano, R. (1985). Patterns and problems of drinking among 

U.S. Hispanics . Unpublished manuscript. Task Force on Black and 
Minority Health, DHHS. 



144 



12. National Institute on Alcohol Abuse and Alcoholism. (1980, August). 

Facts in brief: Alcohol and American Indians . Rockville, MD: 
National Clearinghouse for Alcohol Information. 

13. U.S. Department of Health and Human Services. (1981). Fourth 

special report to the U.S. Congress on alcohol and 
health (DHHS Publication No. (ADM) 81-1080). 
Washington, DC: U.S. Government Printing Office. 

14. May, P. A., Hymbaugh, K. J. , & Aase, J. M. (1983). Epidemiology of 

fetal alcohol syndrome among American Indians of the Southwest. 
Social Biology , 30(4), 374-385. 

15. May, P. A. (1984). Alcohol and drug abuse prevention 

programs for American Indians: Needs and opportunities . 
Prepared for the National Institute on Alcohol Abuse and 
Alcoholism, Division of Extramural Research. 

16. National Institute on Alcohol Abuse and Alcoholism. (1982). 

Special Population Issues . (DHHS Alcohol and Health 
Monograph No. 4). Rockville, MD: Author. 

17. Alcohol Epidemiology Data System. (1984). [Internal report on 

native Hawaiians]. Unpublished raw data, prepared for the 
Director, National Institute on Alcohol Abuse and Alcoholism. 

18. Miller, J. D., Cisin, 1. H. , & Gardner-Keaton, H. (1983). 

National Survey on Drug Abuse: Main findings 1982 . 
Rockville, MD: National Institute on Drug Abuse. 

19. National Institute on Drug Abuse. (1985, May). Drug abuse among 

minorities . Unpublished manuscript. Task Force on Black 
and Minority Health, DHHS. 

20. Decker, M. D., Vaughn, W. K. , Brodies , J. S., Hutcheson, R. H. , 

& Schaffner, W. (1984). Seroepidemiology of hepatitis B in 
Tennessee prisoners. Journal of Infectious Diseases , 
150 , 450-459. 

21. Centers for Disease Control. (1984). Update: Acquired 

immunodeficiency syndrome (AIDS), United States. Centers 
for Disease Control Morbidity and Mortality Weekly 
Report , 33, 661-664. 

22. Mills, J., & Drew, D. (1976). Seerratia Marcescens Endocarditis: 

A regional illness associated with intravenous drug abuse. 
Annals of Internal Medicine , 84 , 29-35. 

23. Joe, G. W., Lehman, W. , & Simpson, D. D. (1982). Addict death 

rates during a four-year posttreatment follow-up. American 
Journal of Public Health , 72, 703-709 . 



145 



24. Joscelyn, K. B., Donelson, A. C, & Jones, R. K. (1980). 

Drugs and Highway Safety 1980 . Ann Arbor, MI: 
University of Michigan Highway Safety Research Institute. 

25. Bureau of the Census. (1981, October). 1980 census of 

population. Standard metropolitan statistical areas 
and standard consolidated statistical areas: 1980 
(PC8G-S1-5). Washington, DC: U.S. Government Printing 
Office. 

26. Frank, B. (1983, June). Drug use among tenants of single 

room occupancy (SRO) hotels in New York City . New York, NY: 
New York State Division of Substance Abuse Services. 

27. National Institute on Drug Abuse. (1983). Main findings 

for drug abuse treatment units, September 1982 . 
Rockville, MD: Author. 

28. Drug Abuse Warning Network. (1985, March). Medical Examiner 

Drug file . Rockville, MD: Alcohol, Drug Abuse, and Mental 
Health Administration. 

29. New York City Police Department. (1982). Homicide analysis . 

New York, NY: Crime Analysis Unit. 

30. Padilla, E. R. , Padilla, A. M. , & Morales, A. (1979). Inhalant, 

marijuana, and alcohol abuse among barrio children and 
adolescents. International Journal of Addictions , 14 , 
945-964. 

31. Langston, J. W. , Ballard, P., Tetrud, J. W. , & Irwin, I. (1983). 

Chronic parkinsonism in humans due to a product of meperidine- 
analog synthesis. Science , 219 , 979-980. 

32. Getting, E. R. , Beauvais, F. , & Edward, R. (1982). Drug use 

among Native American youth: Summary of findings 
(1975-1981) . Fort Collins, CO: Western Behavioral Studies 
Institute. 

33. Department of Health and Human Services. (1985, June). 

Subcommittee report on cancer in minorities . 
Unpublished manuscript. Task Force on Black and Minority 
Health, DHHS . 

34. Office of Smoking and Health. (1984). Differences in 

smoking behavior in minority populations . Unpublished 
manuscript. Department of Health and Human Services. 



146 



35. Darby, C. A. (1985, May). Smoking prevalence among Black 

and White males and females . Washington, DC: Office 
of Smoking and Health. 

36. Glynn, T. J. (1984). Smoking-related cancers and the 

U.S. Black population . Bethesda, MD: National Cancer 
Institute; Smoking, Tobacco, and Cancer Program. 

37. Glynn, T. J. (1984). Prevention and cessation of smoking 

and cancer risk among Hispanic Americans . Bethesda, 
MD: National Cancer Institute; Smoking, Tobacco, and 
Cancer Program. 

38. Marcus, A. C, & Crane, L. A. (1985, February). Smoking 

behavior among U.S. Latinos: An emerging challenge for 
public health. American Journal of Public Health , 
75 (2), 169-172. 



147 



SUBCOMMITTEE ON DIABETES 

EXECUTIVE SUMMARY 

Introduction 

Diabetes mellitus was the seventh leading cause of death in the 
United States in 1980 and is one of the six major contributors to the 
disparity in health status between minorities and nonminorities (1). The 
significance of diabetes as a health problem is increased by its 
association as a risk factor for other major diseases, including 
coronary heart disease and peripheral vascular disease. Complications 
include kidney failure, diseases of the eye, and vascular 
complications that may result in amputations. 

There are two major types of diabetes, according to currently 
accepted clinical definitions. Insulin-dependent diabetes mellitus 
(IDDM) , formerly classified as type I diabetes, accounts for 5 to 10 
percent of all the cases of diabetes in the United States. IDDM may 
occur at any age but typically develops in childhood or young 
adulthood. Specific genetic markers are associated with IDDM. It is 
slightly more prevalent in the White population. Noninsulin-dependent 
diabetes mellitus (NIDDM) , formerly classified as type II, is the more 
common form of the disease, accounting for 90 to 95 percent of all 
cases. Type II diabetes is most often found in middle-aged and older 
adults, especially women. Data from the National Center for Health 
Statistics (NCHS) reveal that diabetes is more prevalent among 
minority groups than in the general population and that the excess of 
morbidity and mortality among minorities occurs overwhelmingly in 
type II (NIDDM). Although national statistics often do not distinguish 
between the two types of diabetes, the dominance of type II is 
significant because the risk factors for the two types are not 
identical. This report focuses on the risk factors and treatment 
issues related to the excess NIDDM in minorities. 

A glucose tolerance test is most commonly used to identify 
diabetes in an individual patient, but this assessment technique has 
changed over time. Consequently, lack of comparability in the 
criteria used to define diabetes in clinical studies is problematic 
when attempting to estimate the extent of diabetes among the minority 
populations. Relatively few reports and studies of minority 
prevalence rates have used the widely accepted National Diabetes Data 
Group (NDDG) criteria for definition of the several types of diabetes. 
In this report, the term diabetes will be used when the two major 
types have not been distinguished, and the term NIDDM will be used 
when data specifically refer to that type as defined by the NDDG. 
Failure to distinguish between the two types of diabetes does not, 
however, change the overall prevalence information, since the 90 to 95 
percent of diabetic people identified in clinical studies, both 
minorities and nonminorities, are noninsulin-dependent diabetics. 



149 



Comparison of mortality data between the White population and the 
minority population shows disproportionately higher mortality rates 
from diabetes among Blacks, Hispanics, Native Americans, and Asian/ 
Pacific Islanders compared with non-Hispanic Whites. 

Blacks 

The prevalence of diabetes is 33 percent higher in the Black 
population than in the White population (2). Data from NCHS show that 
the rate of diabetes is 50 percent greater among Black females than 
the rate in White females. In all populations, NIDDM is related to 
obesity. The prevalence of obesity among Black females is striking 
when compared with the White population as shown in Figure 11 (3). It 
has been shown that the majority of Blacks who are diabetic are 
overweight women. Furthermore, according to several studies, 
complications of diabetes are more frequent among the Black population 
of diabetics when compared with their White counterparts. The 
prevalence of macrovascular disease or large-vessel disease causing 
heart disease and stroke, and microvascular or small vessel disease, 
which leads to kidney failure and blindness, appear to be more 
frequent among Blacks with diabetes than in Whites with diabetes. 

The National Diabetes Control Program, administered by the 
Centers for Disease Control (CDC) , has provided some data on pregnancy 
outcome for Blacks with diabetes, in selected geographic areas. One 
model project in South Carolina revealed that the birth rate per 1,000 
women was higher for Blacks with diabetes compared to Whites with 
diabetes (2). However, the pregnancy outcome among this population 
showed that the perinatal mortality rate among diabetic Blacks was 
three times that of diabetic Whites and 8.5 times that of nondiabetic 
Whites (4). From this and other published reports, it is clear that 
diabetes during pregnancy is associated with a greater number of 
infant deaths among Blacks than Whites. 

Evidence shows that mortality attributed to diabetes increases 
with age in both Whites and Blacks. Until recently, the rate peaked 
at younger ages in Blacks, an effect attributed to the shorter 
lifespan among Blacks and to the conjectured earlier onset of 
disease. 

Native Americans 

Before the 1930s, diabetes mellitus was infrequently diagnosed 
among Native Americans. However, in the past 20 years, diabetes 
mellitus has been recognized as highly prevalent among American 
Indians and Alaska Natives, with diabetes-related mortality rates 2.3 
times higher than in the general population. Among the more than 500 
federally recognized tribes of American Indians and Alaska Natives, 
the prevalence rate of diabetes is highest among the Pima Indians, who 
have the highest rate of diabetes in the world. This rate is 10 to 15 
times higher than the overall United States rate for diabetes and is 
predominantly of NIDDM. Compounding the increased prevalence of 



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diabetes is the associated prevalence of obesity among this tribe. 
Some studies have found that those of full American Indian heritage 
are more susceptible to the disease than those of lesser heritage. 
The implication is that genetic factors play a part in this disease, 
although changes over time suggest behavior as a possible additional 
predispositional factor. Some studies have suggested that the 
increased prevalence of diabetes and obesity among American Indians 
may be related to the ingestion of more calories, less fiber, and less 
physical activity compared to their ancestors. The complications of 
diabetes take a further toll on the American Indian population with a 
significant prevalence of diabetic kidney disease requiring dialysis 
and diabetic retinopathy resulting in blindness. Also, American 
Indians incur disproportionately higher rates of amputations because 
of vascular complications secondary to diabetes (5) . 

Hispanics 

Among the 14.6 million individuals of Hispanic origin in the 
United States, the prevalence rate of diabetes among Hispanic 
Americans is more than three times the rate of the non-Hispanic White 
population (6,7). Although current prevalence data are limited to 
Mexican Americans, the nationwide Hispanic Health and Nutrition 
Examination Study (HHANES) will assess the prevalence of the disease 
in Mexican Americans, Puerto Ricans , and Cuban Americans and will 
evaluate their access to health care services for their diabetes. 
Population-based studies in the southwest United States show that 
Hispanic women in low-income urban barrios are four times more likely 
than Hispanic women living in the suburbs to have the disease, and 
Hispanic men are twice as likely. Although barrio women show a higher 
diabetes rate than barrio men, the ratio is reversed in suburban 
Hispanics. These findings are correlated with higher prevalence of 
obesity among Hispanic women living in the barrio. Obesity, however, 
is probably not the sole contributor to the increased prevalence of 
diabetes among Mexican Americans . This finding may in part be 
clarified by a study of the relation of obesity to acculturation, 
which found that, over time, acculturated Mexican American women 
became less obese; no correlation between acculturation and obesity 
was found for Mexican men (7). Inconsistencies and differences in 
prevalence rates for different clinical studies of Hispanics may be 
complicated by possible genetic contribution from an admixture with 
Native Americans known to be at high risk for diabetes. 

From available data, it is clear that NIDDM is a major health 
burden contributing to excess morbidity and mortality in the Mexican 
American population. The data are still inadequate, however, to say 
with certainty whether this increased prevalence of diabetes is shared 
by other Hispanic subgroups. More data will be forthcoming for Puerto 
Rican and Cuban Americans in the Hispanic HANKS. 



152 



Asian/Pacific Islanders 

Few studies have analyzed data on diabetes among Asian/Pacific 
Islanders. One study with limited information compared Japanese 
Americans living in Hawaii, Los Angeles, San Francisco, and Seattle 
with diabetic Japanese living in Japan. Although not representative 
of the widely different Asian subpopulations , these data are important 
to indicate disparities in one group of the Asian minorities. 
Japanese Americans have exhibited consistently higher rates of glucose 
intolerance, diabetes, and mortality associated with diabetes than 
Japanese in Japan. In most populations, females suffer from diabetes 
more than men. Among the Japanese Americans, however, this situation 
is reversed: Males have higher rates of diabetes than females. 
Diet, which is much higher in fat in Japanese Americans than Japanese 
in Japan, may explain some of the difference in the prevalence of 
diabetes between these groups . Sociocultural effects with 
psychological consequences may likewise contribute to the reversal of 
the ratio between the sexes: older Japanese American men are likely 
to have suffered displacement from their roles as family leaders 
during the reassimilation of Japanese into our culture since World 
War II (8) . Data reviewed on these differences are only suggestive 
and point out the need for additional research on psychological and 
psychosocial correlates to diabetes and its consequences. 

Prevention of Diabetes and Its Complications 

Almost half the cases of diabetes in Americans are likely to go 
unreported, according to the estimate of the American Diabetes 
Association (ADA). Some 10.6 million Americans --about 4.5 percent of 
our population- -may suffer from the disease. Because of the close 
association of diabetes with obesity, it also has been estimated that 
control of obesity could prevent almost 300,000 cases a year. Obesity 
control among minorities, therefore, might prevent a part of the 
disproportionate burden of diabetes experienced by minority 
populations . 

With significant advances in the treatment and the management of 
diabetes during the past decade, increased attention has been paid to 
identifying strategies to reduce the complications of diabetes. 
Exemplary programs that provide continuing outpatient diabetes care to 
populations that are more than 80 percent Black have operated in 
Memphis, Tennessee since 1962 and in Atlanta, Georgia since 1968. 
Both programs use a team approach in educating and treating diabetic 
patients. The major goal of these programs is to prevent or delay the 
development and progression of complications in patients diagnosed 
with diabetes. Reports of results from these programs support the 
hypothesis that a preventive approach to the consequences of diabetes 
is effective in terms of therapeutic effects and cost control (9). 



153 



Since diabetes has reached epidemic proportions among some 
American Indian tribes, the Indian Health Service (IHS) has 
established Model Diabetes Care programs to develop, implement, and 
evaluate the effectiveness of culturally acceptable diabetes 
prevention and management programs (10). During the past six years, 
considerable progress has been made at specific IHS sites in 
delivering high-quality and culturally acceptable diabetes care. 
Although these sites serve only about 10 percent of the IHS service 
population, additional projects have been established recently to 
improve diabetes care and disseminate treatment strategies to other 
communities . 



OPPORTUNITIES FOR PROGRESS 

The following areas were identified by the Subcommittee as most 
significant in narrowing the disparity in the morbidity and mortality 
due to diabetes and its complications between the minority and 
nonminority populations. 

• Availability and distribution of educational and 
informational materials for diabetic patients and those at risk 
of diabetes is vitally important. The scope of the National 
Diabetes Information Clearinghouse should be expanded to 
address the individualized needs of minority groups for 
diabetes-related information. When materials are developed, 
they should take into account the socioeconomic and educational 
levels of their target populations and, when appropriate, their 
language needs . 

• Under the auspices of the National Diabetes Advisory Board, 
DHHS should support the development and inclusion of culturally 
specific materials in the education and certification process 
of diabetes educators . 

• As part of the educational process of both patients and health 
care provider trainees, the synergistic effects of smoking, 
hypertension, hyperlipidemia, and obesity should be stressed as 
having adverse effects on the optimal management of diabetes. 

• DHHS- and State-funded CDC Diabetes Control Programs, 
which have fostered participation of State and Federal 
efforts in diabetes control, have demonstrated positive impact. 
States should be encouraged to continue these programs. 

• Existing federally funded programs such as the Women, Infants, 
and Children (WIC) programs and nutrition programs for the 
elderly should be used as possible opportunities 

to screen high-risk minority individuals for diabetes. 



154 



• It is believed that earlier treatment of asymptomatic 
diabetes can prevent diabetic complications inasmuch as it is 
the complications rather than the diabetes per se that are 
responsible for much of the diabetes-related morbidity and 
mortality. Because NIDDM is more likely to occur in those over 
age 50, blood glucose screening or measurement of the 
glycosylated hemoglobin (hemoglobin AlC) in minority 
individuals may be appropriate. ^ 

• The DHHS should encourage State and local health departments to 
address the needs of those who have diabetes in areas where high 
concentrations of minority populations are located. DHHS, 
through CDC and the National Diabetes Information Clearinghouse, 
can provide information and technical assistance to facilitate 
State and local diabetes control activities. 

• Private organizations concerned with diabetes such as the 
ADA and the American Association of Diabetes Educators should 
be encouraged to focus some of their efforts and resources on 
issues specific to minority populations. 

• In federally sponsored programs, DHHS should emphasize aspects of 
diabetic care related to prevention of diabetic complications 
that are the sequelae to poor diabetic control. 

• Encouragement should be given to developing curricula 

for health care providers that are minority and culturally 
sensitive and to expanding the role of certain health 
professionals such as dietitians and nurse practitioners 
in the care of people with diabetes . 

• Additional research on the prevalence of diabetes and its 
complications among the various minorities is needed. 
Well-designed epidemiologic studies are needed to characterize 
the distribution of diabetes among minorities and monitor 
trends in both prevalence of diabetes and related 
complications. Studies should elucidate the effects of 
variables such as physiologic differences, influences of 
various diets, acculturation, and genetic admixture on the 
pattern of disease. 

• Environmental factors should be examined as possible 
contributors to the increased prevalence of diabetes during the 
past four decades among Native Americans, Blacks, Asian/Pacific 
Islanders, and Hispanics . 

• The DHHS should encourage the development of national data on the 
prevalence of diabetes and its complications among the minority 
groups by oversampling the minority populations in national 
surveys . 



155 



REFERENCES 

1. Drury, T. , Harris, M. , & Lipsett, L. (1981). Health: United 

States, 1981. Prevalence and management of diabetes . 
Washington, DC: U.S. Department of Health and Human Services. 

2. Rosemann, J. F. (in press). Diabetes in Black Americans. In M. 

Harris (Ed.), Diabetes Data Book . 

3. Bonham, G. S., & Brock, D. W. (1985). The relationship of diabetes 

with race, sex, and obesity. American Journal of Clinical 
Nutrition , 41, 776-783. 

4. Wheeler, F. C, Collmar, C. W., & Deeb, L. C. (1982). Diabetes 

and pregnancy in South Carolina. Diabetes Care , 5, 561-665. 

5. Sievers, M. L. , & Fisher, J. R. (1981). Diseases of North 

American Indians. In H. Rothschild (Ed.), Biocultural Aspects 
of Disease . (p. 191-240). New York, NY: Academic Press. 

6. Bureau of the Census. (1981). Age, sex, race, and Spanish 

origin of the population (Supplementary report PC-80-51-1). 
Washington, DC: U.S. Department of Commerce. 

7. Stern, M. (1984). Factors relating to increased prevalence 

of diabetes in Hispanic Americans . Unpublished manuscript. 
Task Force on Black and Minority Health, DHHS. 

8. Fujimoto, W. Y. (1984). Diabetes in Asian Americans . 

Unpublished manuscript. Task Force on Black and Minority 
Health, DHHS. 

9. National Diabetes Advisory Board. (1983). Diabetes mellitus, the 

continuing challenge . (DHHS Publication No. (NIH) 83-2624). 
(p. 496-3583). 

10. Davidson, J. (1985). Diabetes . Unpublished manuscript. Task 

Force on Black and Minority Health, DHHS. 



156 



SUBCOMMITTEE ON HOMICIDE, SUICIDE, 
AND UNINTENTIONAL INJURIES 

EXECUTIVE SUMMARY 

Introduction 

Injuries, intentional and unintentional, are among the leading 
causes of death in the United States. This Subcommittee investigated 
the major disparities in mortality between the majority population and 
Blacks, Hispanics, Native Americans, and Asian/Pacific Islanders in 
the areas of homicide, suicide, and unintentional injuries. Of these, 
homicide and unintentional injuries account for 35 percent of the excess 
deaths in Blacks under age 45 years. They remain important contributors 
for Hispanics and Native Americans as well. 

Since the reordering of national health priorities that resulted 
in the Surgeon General's 1979 report. Healthy People , homicide 
increasingly has been recognized as a preventable public health 
problem for which the health sector needs to devote greater attention 
and energy. Traditionally, problems of violence and homicide have 
been left to the criminal justice system. Prevention of homicide is a 
new endeavor for public health, and it presents an opportunity for the 
public health field to deal with a previously ignored health problem. 

In 1983, homicide accounted for more than 19,000 deaths in the 
United States, an overall rate of 8.2 deaths per 100,000 population, a 
rate far higher than that of any other industrialized Nation (1). 

Homicide is the 11th leading cause of death in the United States. 
For Americans of ages 1 through 65, homicide accounts for more than 
726,000 potential years of life lost annually, an index for which 
homicide ranks fourth among all causes of death. (Potential years of 
life lost were computed to age 65. Data were computed from NCHS 
public use data tapes by the Violence Epidemiology Branch, Centers for 
Disease Control.) After heart disease, homicide accounts for more 
excess mortality among Black Americans than any other cause of death. 

Analysis of national and local homicide data indicates that Black 
males and females and Hispanic males have rates of death far in excess 
of the rates of their peers in the general population (see Figures 12 
and 13) . Native Americans have rates of death from unintentional 
injuries far greater than the general population. Suicide and 
homicide also occur at higher rates among the Native American 
population. Chinese women over age 45 have suicide rates 
significantly in excess of those for White women of comparable age. 



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Blacks 



• In 1983, Blacks accounted for 43 percent of homicide victims, 
although Blacks represent only 11.5 percent of the population (2). 

• Black males have a 1 in 21 lifetime chance of becoming a homicide 
victim. The chance for White males is 1 in 131 (3). 

• Black females have a 1 in 104 lifetime chance of becoming a 
homicide victim. The chance for White females is 1 in 369 (3). 

• Higher Black homicide rates are found in all regions of the 
United States but are particularly high in the largest cities 
of the Nation (data compiled by the Task Force on Black and 
Minority Health) . 

• Black males have the highest rates of homicide: 69.2 per 
100,000 for Black males compared with 10.3 per 100,000 among 
White males, in 1981 (1). 

• Black females have the second highest rate of homicide: 12.9 per 
100,000 compared with 3.1 among White females, in 1981 (1). 

• Homicide is the leading cause of death for Black males of ages 
15 to 44 (1). 

• The homicide rate for Black males, ages 15-24, in 1981, was 78.2 
deaths per 100,000 population compared with 14.4 per 100,000 
for White males 15 to 24 years of age, a difference of more 
than five-fold (1). 

• The homicide rate for Black males, ages 25 to 34 years, was 
136.9 per 100,000 in 1981 compared with 17.6 for White males of 
the same age group, 7.8 times as great (1). 



Hispanics 



National data are not available for homicide deaths among Hispanic 
populations, but data from the five-State southwestern region, 
where more than 60 percent of Hispanics reside, show that during 
the period 1976 to 1980, the homicide rate was 21.6 per 100,000, 
more than 2.5 times the rate of the non-Hispanic White population 
(7.7 per 100,000) in the same geographical area (4). 



Native Americans 



The homicide rate among American Indians in 1980 was 18.1, 70 
percent higher than the rate for the general population (5) . 



160 



• American Indians have the highest rate of death from unintentional 
injuries or "accidents," both overall and at age-specific inter- 
vals. In 1980, the death rate from accidents among American 
Indians was 107.3 per 100,000, significantly greater than the 
rate of 42.3 per 100,000 for the U.S., all races. Motor vehicle 
injuries account for the majority of accidental deaths. Among 
American Indians, the death rate from motor vehicle injuries 

was 61.3 per 100,000 American Indians compared to 22.9 for the 
United States aggregate population (5). 

• The death rate from suicides among American Indians was 14.1 per 
100,000 in 1980, approximately 20 percent greater than the 
general population (5). Within some tribes, the rate is much 
higher. American Indian suicide victims are generally younger 
than those in the general population with suicide rates peaking 
at ages 15 to 39, compared with the general population in which 
suicides most often occur after age 40 (7). 

Asian/Pacific Islanders 

• The risk for suicide in Chinese females rises considerably after 
age 45 and increases with advancing age (6) . 

Selected Dimensions of Homicide 

Homicide is seldom an isolated event. Much homicide is preceded 
by nonfatal conflicts and violence that come to the attention of police 
or are the occasion for visits to hospital emergency departments. 

• Most homicides in the United States involve relatives and 
acquaintances. Of all homicides in 1983, 19 percent were 
committed by members of the victims' families, 38 percent by 
acquaintances, 15 percent by strangers; offenders were unident- 
ified in 28 percent. 

• Most homicides are committed against persons of the same race 
as the offender. In 1983, 94 percent of Black victims were 
slain by Black assailants, 88 percent of White victims were 
slain by White assailants (8). 

• Among Black males of ages 15 to 24: 

--more than 65 percent of homicide deaths in 1979 were not re- 
lated to criminal events. 

--54 percent of homicide victims were killed by persons known 
to them, usually acquaintances (8). 

• Approximately 60 percent of all homicides are committed with 
firearms --handguns , rifles, or shotguns (7). 



161 



Factors Associated with Homicide 

Considered as a public health problem, the high homicide rate can 
be related to psychological factors related to mental processes and 
behavior; external environment including physical, historical-cultural, 
social, educational, and economic environments; lifestyle, or individual 
and group ways of life, and physiological factors related to age and 
gender . 

• Psychological factors. Homicide differs from other health 
problems in that it is the outcome of mental processes that 
result in conscious efforts to inflict physical harm upon another 
human being. There appears to be broad agreement that persons 
who commit homicide and other violent crimes fall into one of 

a number of groups. These include: 

--Normal, adequately socialized people exposed to extremely 
provocative or frustrating situations or circumstances. In 
some instances, their violence tendencies are exacerbated by 
inhibition- lowering drugs. 

--Persons committed to a violent lifestyle with supporting 
attitudes and values. This includes both normal individuals 
who consider that violence is appropriate in certain circum- 
stances and other individuals who fail to develop adequate 
inhibitions against violent behavior because of disturbed 
developmental patterns. Although personal characteristics are 
related to participation in violence, actual violent behavior 
results from interactions of individuals with their environments, 
Among the external factors that facilitate or impede violent 
behavior are cultural attitudes towards violence, socioeconomic 
conditions, and availability of weapons. 

• Environment. Although occupying one of the most healthful 
physical environments in the world, the United States has long 
had higher levels of internal violence than other 
industrialized nations. Violence is also accepted in American 
culture to a degree exceeding that of many other nations. 
Television programs, movies, and printed media often present 
violence as entertainment to the American public. 

Within the United States, as in other western countries, rates 
of homicide are highest in large cities. Numerous studies 
conducted over a period of many years note that violent crime, 
its offenders, and its victims are most often found in urban 
areas characterized by low income, physical deterioration, 
welfare dependency, disrupted families, lack of social 
supports, low levels of education and vocational skills, high 
unemployment, high proportion of single males, overcrowded and 
substandard housing, low rates of home ownership or single 
family dwellings, mixed land use, and high population density (9). 



162 



Blacks live in a society that has a long tradition of 
discrimination against minorities. Hispanics , Asians, and 
Native Americans have also been victims of discrimination. 

• Lifestyle. Several types of behaviors are associated with 
increased risk for homicides. The National Institute on Alcohol 
Abuse and Alcoholism has estimated that about one-half of all 
homicides in the United States are related to use of 

alcohol (10). An estimated 10 percent of homicides nationwide 
are associated with use of illegal drugs (estimated by Research 
Triangle Institute, North Carolina). In some of the 
Nation's largest cities, the number of drug-related homicides 
is more than 20 percent (11). 

• Physiological factors. Being male and being young are the most 
prominent risk factors for involvement in homicide as a victim 
or as a perpetrator. 



OPPORTUNITIES FOR PROGRESS 

Many, if not most, homicides are preceded by patterns of nonfatal 
violence that can provide targets for efforts at prevention (12). 
Research indicates that homicide often is the end product of 
youthful training in the use of violence that began in the home and 
through interactions with peers in school and communities (13). 
Children who engage in persistent antisocial and violent behavior 
from an early age are at significant risk for becoming deficient in a 
variety of social skills, including education, communication, and 
work habits that are essential to a well-adjusted adult life (14). 

Development of Preventive Intervention Strategies 

Enough is known about homicide risks to suggest some useful 
starting points for applying public health concepts of primary, 
secondary, and tertiary prevention. As interventions in these areas 
are developed and tested over time, some demonstrably effective 
prevention strategies may emerge. 

Primary Prevention 

Primary prevention in the public health sense involves averting 
the initial occurrence of a disease, defect, or injury. In the case 
of homicide, primary prevention efforts need to be directed at those 
social, cultural, technological, and legal aspects of the environment 
in the United States that facilitate perpetuation of the Nation's 
extraordinarily high homicide rates. The following examples 
illustrate the types of preventive strategies that need to be 
developed. Implementation of these strategies will require that 
health professionals join with others in an effort to eradicate 
factors that impair health by facilitating homicide. 



163 



• Effective health strategies to prevent homicide must begin by 
enlisting greater public and professional interest and concern. 
The Public Health Service should take the lead in developing a 
new health promotion campaign specifically focused on homicide. 
The campaign should increase public and professional awareness 
that homicide is a serious national problem and that it is 
preventable. By comparing the American homicide rate with 
that of other nations, the campaign can also convey the message 
that the high rate of American homicide can no longer 

be tolerated. 

• Physicians and other health care providers need to develop 
greater understanding of homicide as a public health problem 
for which the health sector should accept greater responsibil- 
ity. Information on homicide and other violence should be 
incorporated into the curricula of medical schools, nursing 
schools, schools of social work, and continuing professional 
education. 

• Community self-help. High rates of homicide and other violence 
are problems for which Black, Hispanic, and Native American 
communities need to accept greater ownership. By accepting 
responsibility for homicides that occur within their own 
communities, minority citizens empower themselves to press more 
actively for adequate and comprehensive efforts at prevention. 
Community approaches might include: 

--developing a continuing media campaign to educate the community 
and the general public that violence and high homicide rates 
are unacceptable. Messages should be culturally relevant and 
feature appropriate role models who are suitable for the target 
population. 

—establishing a consortium or community council of civic, 
religious, political, youth, and other community leaders who 
are committed to the proposition that violence and homicide in 
the community are unacceptable and preventable. This group 
would meet regularly to exchange ideas and information and, 
with help from other experts if needed, would develop 
constructive approaches to prevention of violence and homicide. 

--developing an information bank on violence and homicides that 
occur in the community. 

--mobilizing community resources to maximize the potential for 
violence reduction and homicide prevention. 

--developing a community policy toward firearms. 



164 



--developing model programs for community-based homicide 
prevention. Promising approaches are provided by such 
projects as the House of Umoja in Philadelphia (15), which has 
reduced gang-related homicides among young Black men; 
Neighborhood Crime Prevention projects, and the "Big Brother" 
program, which could provide Black role models for high-risk 
children from single-parent families. 

--reducing violence on television. Several consumer and 
professional groups have begun advocating reduction of 
television violence. The National Parent Teachers Association 
and other organizations have issued program selection 
guidelines to enable parents to choose programs that demonstrate 
appropriate prosocial behavior. 

Secondary Prevention 

Secondary prevention in the public health sense involves halting 
or slowing the progression of a disease or other health problems. In 
the case of homicide, secondary prevention efforts should be directed 
to individuals manifesting early signs of behavioral and social 
problems that are logically and empirically related to increased risks 
for subsequent homicide. Family violence, childhood aggression, 
school violence, adolescent violence, alcohol abuse, and drug abuse are 
important focal points for efforts at secondary prevention of 
homicide. In the case of Black and Hispanic homicide, such preventive 
efforts are particularly needed in low-income, inner-city communities 
characterized by high rates of violence, family disorganization, 
unemployment, and school drop out. 

• Family violence. More programs targeted to minority populations 
should be implemented to assist parents in parenting skills and 
in providing effective discipline that avoids excessive 
punishment . 

• School-based education programs. Health education curricula 
extending from elementary through high school should include 
teaching children how to manage hostility and aggression by 
nonviolent means and channeling children's energies into 
education, work, community projects, and recreation. The Boston 
Youth Program is an example of an innovative school-based program 
for homicide prevention (16). 

• Mental health programs. Because aggressive and antisocial 
behaviors in children are often associated with later delinquency 
and violence, improved mental health interventions are needed. 

• Chemical dependency. Programs to reduce chemical dependency need 
to be incorporated into strategies aimed at prevention of homicide, 
suicide, and unintentional injuries in minority populations. 



165 



Tertiary Prevention 

Tertiary prevention is concerned with situations in which a 
health problem is already well established, but efforts can still be 
made to prevent further progress toward increased disability and 
death. In relation to homicide, the problems of greatest concern are 
types of serious violence between intimates and acquaintances that are 
associated with elevated risk for homicide. Preventive efforts 
include: 

• Hospital emergency departments can help to prevent homicides 
through improved medical record keeping on assaults. Homicides 
frequently are preceded by nonfatal assaults that bring victims 
into hospital emergency rooms. Records should include complete 
information on the circumstances of an assault and a method 
for identifying repeat victims of assaults. Blood alcohol 
levels should be measured and recorded as should evidence, if 
any, of drug use. 

• Improved medical protocols need to be developed for identifying 
female victims of domestic violence. Many of these persons are 
not identified as battering victims because they do not 
volunteer this information and are not questioned about 
possible battering. A model emergency room protocol for 
identifying adult victims of domestic violence has been 
developed for hospitals in the State of New York and can be 
adapted for use elsewhere (17). 

• Preventive interventions for victims of domestic violence should 
be introduced and tested in health care settings. A leader in 
this field has been the Harborview Medical Center in Seattle, 
which has developed a comprehensive intervention model that 
addresses the needs of victims of spousal violence, child 
sexual abuse, rape, elder abuse, and assaults by strangers (18). 

• High rates of minority youth homicide in the Nation's largest 
cities are associated from time to time with violence that 
develops among rival youth gangs. The House of Umoja in 
Philadelphia provides an example of a successful, minority-directed 
program aimed at prevention and reduction of gang homicide. An 
important outcome of this effort was the formation of a community 
agency, Crisis Intervention Network, that has worked to prevent 

a resurgence of gang violence through communication with concerned 
parties and organizational efforts to combat the environmental 
and social conditions that foster gang violence (15). 

Interventions Targeted Toward Native Americans 

• The Indian Health Service (IHS) is focusing greater efforts at 
reducing death and disability from unintentional injuries, suicide, 
and homicide by improving: 



166 



--prevention activities in the form of health education, risk 
identification, and working with other agencies responsible for 
law enforcement programs . 

--assistance to injury victims through improved IHS clinical 
services, emergency medical services, including assisting 
communities to improve ambulance services. 

--rehabilitation through clinical services and alcohol programs, 
mental health, and health education. 

--providing medical personnel with training in emergency care 
skills . 

• Efforts to prevent injuries from motor vehicle accidents should 
include encouraging use of seat belts and child restraints in 
cars and trucks, use of helmets for motorcyclists, and restraints 
for passengers riding in the backs of pickup trucks. 

• Because American Indian tribes differ considerably in language, 
culture, and traditions, consultation with tribal leaders is 
vital when planning or implementing health interventions targeted 
toward American Indians. 

Efforts at preventing or reducing unnecessary deaths from 
homicide, suicide, and unintentional injuries in all minority 
populations require a cooperative approach from diverse disciplines 
outside the traditional public health sector. 



167 



REFERENCES 



1. National Center for Health Statistics. (1984, December). 

Health, United States 1984 . (DHHS Publication No. (PHS) 
85-1232). Washington, DC: U.S. Government Printing Office. 

2. Federal Bureau of Investigation. (1984). Uniform crime reports 

of the United States, 1983 . Washington, DC: U.S. 
Department of Justice. 

3. U.S. Department of Justice. (1985, May). The risk of 

violent crime . Washington, DC: Author. 

4. Smith, J. C, Mercy, J. A., & Rosenberg, M. L. (1984). 

Comparison of homicides among Anglos and Hispanics 

in five southwestern states . Atlanta, GA: Centers for 

Disease Control. 

5. Indian Health Service. (1984, June). Indian Health Service 

chart book series (No. 421-166:4393). Washington, DC: 
U.S. Government Printing Office. 

6. Liu, W., & Yu, E. (1985). Ethnicity and mental health. In 

J. Moore, & L. Maldonaldo (Eds.), Urban Ethnics . Beverly 
Hills, CA: Sage Publications. 

7. Baker, S. P., O'Neill, B., & Karpf, R. S. (1984). The injury 

fact book . Lexington, KY: Lexington Books, D.C. Heath and 
Company. 

8. Rosenberg, M. L., Gelles, R. J., Holinger, P. C, Zahn, M. A., 

Conn, J. A., Fajman, N. N. , &. Karlson, T. A. (1984). 
Violence, homicide, assault, and suicide. Closing the gap 
health policy project . Unpublished manuscript. 

9 . President's Commission on Law Enforcement and Administration of 

Justice: The Challenge of Crime in a Free Society . (1967). 
Washington, DC: U.S. Government Printing Office. 

10. John, H. W. (1978). Alcoholism and criminal homicide: A 

review. Alcohol Health and Research World , 2, 8-13. 

11. New York City Police Department. (1982). Homicide analysis . 

New York, NY: Crime Analysis Unit. 

12. Hawkins, D. F. (1984, December). Longitudinal -situational 

approaches to understanding Black-on-Black homicide . 
Unpublished manuscript, Task Force on Black and Minority 
Health, DHHS. 



168 



13. Petersilia, J. (1980). Criminal career research. A review of 

recent evidence. In N. Morris, & M. Tonry (Eds.), Crime and 
Justice (Vol. 2). Chicago, IL: University of Chicago Press. 

14. Loeber, R. (1982). The stability of antisocial and delinquent 

child behavior: A review. Child Development , 53 , 1431-1446. 

15. Falakah, F. (1984). Call and catalytic response: The House 

of Umoja. In R. Mathias, P. DeMuro, & R. Allinson (Eds.), 
Violent juvenile offenders. An Anthology (pp. 231-237). 
San Francisco, CA: San Francisco National Council on Crime 
and Delinquency. 

16. Prothrow-Stith, D. (1985, January). Interdisciplinary 

interventions applicable to prevention of interpersonal 
violence and homicide in Black youth . Unpublished 
manuscript. Task Force on Black and Minority Health, DHHS . 

17. State of New York Department of Health. (1984, August 19). 

Hospital emergency department protocol: Identifying 

and treating adult victims of domestic violence 

(Health Facilities Series H-48) . New York, NY: Author. 

18. Klingbeil, K. (1985, January). Comprehensive model to detect, 

assess, and treat assaultive violence in hospital settings . 
Unpublished manuscript. Task Force on Black and Minority Health, 
DHHS. 



169 



SUBCOMMITTEE ON INFANT MORTALITY AND LOW BIRTHWEIGHT 

EXECUTIVE SUMMARY 

Introduction 

The death of an infant is a personal tragedy and an event that 
causes us to look at the functioning of medical and social systems. 
Infant mortality, the rate at which babies die before their first 
birthday, has been viewed historically as a sensitive indicator of the 
well-being of these systems. Under age 60, the rates of death from 
infant mortality are higher than for any other cause of death. In 
1983, there were 39,400 infant deaths, a provisional rate of 10.9 per 
1,000 births (1). While this represents a striking decline during the 
20th century (from about 100 deaths per 1,000 live births in 1900) the 
United States does not compare favorably with other industrialized 
nations. Infant mortality rates are lower in the Scandanavian 
countries, Japan, most of Western Europe, Canada, and Australia (2). 
Although Blacks have shared in the decline in infant mortality, a 
significant disparity remains with Black rates being essentially twice 
those of Whites, 20.0 versus 10.5 in 1983, depicted in Figure 14. 

Infant mortality rates have two main components: neonatal 
mortality rate or deaths of infants within the first 28 days of life, 
and postneonatal mortality or deaths from 28 days to one year. At the 
turn of the century, postneonatal deaths accounted for most infant 
deaths, but presently, neonatal deaths are predominant (Figure 15). 
Neonatal deaths are thought to reflect preexisting health conditions 
of the mother and the medical care she and her baby receive during 
pregnancy, at the time of delivery and shortly thereafter. There have 
been major improvements in the neonatal death rate in the past two 
decades. Postneonatal mortality is more reflective of living 
conditions, quality of care for children and medical care for 
treatable conditions such as infections. Of course, these two sources 
of risk for babies are not separate since the factors that influence a 
woman to obtain early prenatal care may be the same things that 
influence the quality of parenting and availability and use of 
services after the birth (3) . 

The sources of data for infant mortality are death certificates 
filed by States, which are then reported to the National Center for 
Health Statistics. States vary in their reporting of other 
characteristics of mothers and infants, which limits analysis of 
infant mortality by ethnicity. Other data sets such as birth 
certificates and surveys provide more data on ethnicity and include 
information on birthweight, which is a major risk factor for infant 
mortality. Insight into the variability of poor pregnancy outcome can 
be obtained by looking at low birthweight (LBW) , specifically, the 
proportion of births that are below 2,500 grams, about 5-1/2 pounds. 



171 



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The distinction between normal and low birthweight is a powerful one 
in regard to infant mortality, but LBW actually includes two 
subgroups: preterm deliveries and small for gestational age babies, 
which may or may not be preterm. In the research projects and data 
that are described here, it is not always possible to distinguish 
these two subgroups, although they are discussed in some detail in the 
full report. 

Although less than seven percent of babies are born with low 
birthweight, they contribute two-thirds of the deaths in the first 
month of life and approximately 60 percent of all infant deaths (4) . 
Among White babies, 5.6 percent are LBW as opposed to 12.4 percent for 
Black babies. Puerto Ricans occupy an intermediate position (9.1 
percent). Other Hispanic groups show better outcomes, approximately 
5.7 percent for Mexicans and 5.8 percent for Cubans. Data for 
Hispanics are based on reports from 22 States which encompass an 
estimated 90 percent of Hispanic births. Asians generally show good 
perinatal outcomes. The best outcomes are among Chinese (5.3 
percent), while 6.9 percent of Filipino births are below 2,500 grams. 
Data for American Indians show favorable birth outcomes and low 
birthweight rate of 6.2 percent (Figure 16) (5). A number of factors 
have been identified as relating to the risk of low birthweight and 
infant mortality. The broad range and complexity of these problems 
should lead to caution in presuming quick or simple solutions to the 
problem of infant mortality in the United States or the disparity 
between groups. This report addresses what we know about etiologic 
factors, recommendations for immediate action, and areas where 
reasearch is needed. 

Etiologic Factors 

The many risk factors associated with poor perinatal outcome 
among minorities that appear to be related to low socioeconomic status 
include: (1) low income and inadequate insurance coverage that often 
reduce access to appropriate medical care, (2) preexisting disease 
conditions, (3) poor nutrition, (4) inadequate housing and crowded 
living conditions, (5) limited maternal education, (6) stressful work 
environments, (7) disrupted families and lack of social supports, and 
(8) problems of transportation and child care that impede use of 
services. All are more prevalent among poor and minority women. 
Furthermore, childbearing patterns are related both to pregnancy 
outcome and ethnicity. Populations with worse pregnancy outcomes tend 
to include more teenage mothers, more unmarried mothers and more 
unintended births (Table 15). This report addresses how the factors 
leading to pregnancy and the care received during pregnancy relate to 
the well-being of the baby. When many of the social risk factors 
(education, marital status, trimester of first care, parity, age) are 
controlled, Black women still have twice the risk of bearing LBW 
babies as do comparable Whites. Nevertheless, the group of Black 
women controlled for social risk factors has half the LBW incidence of 
the Black population as a whole. This finding cautions us that this 



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Table 15 



Childbearing Patterns Among Racial and Ethnic Groups, 1982 













American Indian, 




White 


Black 


Hispanic* 


Asian 


Alaska Native 


Age of Mother 












Under 15 


4,153 


5,395 


1,288 


88 


126 


15-19 


357,948 


140,534 


60,369 


6,278 


8,749 


20-24 


958,509 


207,640 


115,275 


23,872 


15,364 


25-29 


961,053 


143,748 


90,393 


36,303 


10,236 


30-34 


503,847 


69,781 


47,999 


26,394 


4,886 


35-39 


136,664 


21,341 


18,056 


8,146 


1,627 


40-44 


19,027 


3,966 


3,809 


1,351 


287 


45-49 


853 


236 


201 


131 


14 



Percent of Births to Mothers Under Age 20 

12.3 24.6 



18.3 



6.2 



21.5 



Percent of Births to Mothers Over Age 35 

5.3 4.3 



6.5 



9.4 



4.7 



Marital Status: Out-of-Wedlock Births 

Number 355,180 335,927 86,488 8,642 14,998 

Percent 12.1 56.7 25.6 8.4 36.3 



Parity 












Percent First Births 


43.3 


39.2 


37.0 


41.8 


36.9 


Percent High Parity (4-I-) 


8.6 


14.2 


16.4 


10.7 


17.0 



SOURCE: National Center for Health Statistics. 

*Refers to births to residents of 23 States reporting Hispanic origins of the mother on birth certificates. These States accounted 
for an estimated 95 percent of all births of Hispanic origin in the United States in 1982. 



176 



is a difficult, complex issue that offers no simple solutions. 
Although much is known about the risks for LBW and infant mortality, 
much remains to be learned. 

Based on the review of literature and NCHS data, four major areas 
can be highlighted: 

• The importance of family planning/pregnancy prevention 
among teenagers , given the disproportionate number of teen 
parents who are minorities. 

• The importance of assuring early and continuous prenatal 

care and appropriate levels of maternity, newborn, and infant care 
to minority women. 

• The importance of aggressive outreach, case management, and 
expanded patient education services for minority women. 

• The importance of adequately financing the providers and 
hospitals that care for minority women, who are often uninsured 
or rely on Medicaid. 

Blacks 

The neonatal mortality rate (NMR) for Blacks in 1981 was 13.4 per 
1,000 live births, almost twice the rate for Whites (7.1). The 
postneonatal mortality rate (PNMR) for Blacks was 6.6, twice the 
3.4 rate for Whites (6). In 1983, 11,060 Black babies died before one 
year of age (1) . 

There are three components of excess risk for infant mortality 
for Blacks: increased risk of bearing a low birthweight baby; 
increased risk of neonatal death among normal weight babies; and 
increased risk of postneonatal death, regardless of birthweight, 
relative to Whites. These risks are related to (but not fully 
explained by) childbearing patterns. Black women are much more likely 
to have a teenage birth, an out-of-wedlock birth, or a high parity 
birth, all of which are more likely to be unintended and associated 
with adverse perinatal outcome. 

A focal point for lowering infant mortality is to improve 
services designed to help women, especially teenagers, avoid unwanted 
pregnancies. Pregnant Black women are less likely to receive prenatal 
care early in pregnancy. In 1982, 61 percent of Black mothers 
received care in the first trimester compared with 79 percent of White 
mothers. Black mothers were twice as likely as White mothers (10 
percent versus 5 percent) to receive either no care or care beginning 
in the third trimester of pregnancy (5). It is also possible that 
there is a biologic role influencing birthweight that gives a 
different meaning to low birthweight for Blacks than for Whites. This 
issue deserves research attention. It is clear, unfortunately, that 
normal weight Black babies have far higher rates of neonatal mortality 



177 



than White babies. This may reflect the prenatal care received, other 
health behaviors of the mothers, quality of care in hospitals 
providing routine obstetrical care, or other factors. To the extent 
that deaths occur after the baby has left the hospital, excess deaths 
may reflect living conditions or health knowledge and health behavior 
on the part of the mother and family. 

Postneonatal mortality rates are higher for Blacks for all major 
causes of death except congenital anomalies. Sudden infant death 
syndrome (SIDS) is the leading cause of postneonatal death, and 
research is continuing on its causes and prevention. Accidents are 
another major cause of death and may be related to dimensions of 
living conditions, knowledge of health behaviors, or quality of care 
provided to children (7). Among all groups, the mother's education is 
strongly associated with infant mortality, presumably because it taps 
these dimensions, as well as reflecting access to well and sick baby 
health care services. There are a number of specific risks regarding 
adverse pregnancy outcome such as the role of stress or infection that 
are suspected of influencing the disparity between Black and White 
rates. Specific health conditions related to perinatal outcome among 
Blacks are discussed in the report. In many cases, research currently 
under way should add to the presumptive evidence for the effect of 
these factors or their relationship with race. The relationship of 
economic conditions to health, especially infant mortality, is another 
area that deserves further research. The Subcommittee urges that 
further research address these factors. 

Hispanics 

As the second largest minority group, Hispanics present a complex 
picture in terms of low birthweight and infant mortality. There is 
considerable variation within the Hispanic population, and while 
postneonatal mortality rates are elevated, the birthweight 
distributions are generally favorable. Subgroups must be discussed 
separately, however. 

Mexican Americans 

As the largest component of the Hispanic population in the United 
States, and given their geographic concentration, there are more data 
on Mexican Americans than for other groups. Babies of Mexican 
American mothers have a relatively good birthweight distribution, 
which is somewhat surprising given their social and economic 
characteristics. Demographically, Mexican American women have fairly 
high rates of teen childbearing and more high-parity births. Their 
rates of out-of-wedlock childbearing are lower than those for Black 
women (but higher than those for Whites), and there is a greater 
tendency to be in a two-parent household than among Black mothers. 

Only 58 percent of Mexican American mothers begin prenatal care 
in the first trimester, less than for Blacks or non-Hispanic Whites (5) 
The neonatal mortality rate appears good in some analyses, but 



178 



other studies suggest that rates are artificially low due to 
underreporting (8). Recent studies suggest that, compared with 
non-Hispanic Whites, Mexican Americans have higher neonatal mortality 
at any particular birthweight (9). 

This debate draws attention to the data and research needed to 
address the interrelationships among intrinsic birthweight 
distribution, health behaviors and prenatal care, and the access to 
and use of health care services. For Mexican Americans, the question 
of how individual health endowments and behaviors affect perinatal 
outcome are complicated further by the role of migration. The 
selectivity of migration may mean that Mexican women who migrate to 
the United States represent a selected, or healthier, subgroup. 
Because many Mexican American women are of low socioeconomic status, 
issues regarding access to subsidized care are extremely important to 
them and to the outcome of their pregnancies . 

Puerto Ricans 

The birthweight and hence infant mortality rates for United 
States -born Puerto Ricans are less favorable than those for Mexican 
Americans. The low birthweight rate is 9.1 percent overall and 9.6 
percent for United States -born Puerto Ricans. This is the highest for 
any Hispanic group. The proportion of low birthweight is between the 
rates for Whites and for Blacks. This is not too surprising because 
their childbearing rates are in many ways more like patterns seen in 
the Black population than those seen among other Hispanics. For 
example, among Puerto Ricans, 48 percent of births were out of 
wedlock, but among Mexican Americans, it was only 14 percent. The 
economic circumstances of many Puerto Rican women are such that 
considerations regarding socioeconomic status, access to health care, 
and health education and behaviors that apply to Blacks, apply to 
Puerto Ricans as well. Fuller understanding of the differences among 
the several Hispanic populations requires better data systems that 
collect information on ethnicity and requires creative ways of dealing 
with data for small subpopulations . 

Cubans and Other Hispanics 

Data on birthweight show a favorable distribution for Cubans. 
The low birthweight rate for Cubans is 5.8 percent; it is somewhat 
higher among United States -born Cuban mothers. This is not 
surprising, given their apparently better socioeconomic status than 
that of Mexican American or Puerto Rican women. For example, Cuban 
women have a relatively low proportion of births occurring 
out-of-wedlock (14 percent) and high rates of use of prenatal care (80 
percent beginning in the first trimester) . It is not presently 
possible to construct mortality rates for Cuban births; moreover, much 
of the research does not provide sufficient information on ethnicity 
or a large enough number of cases to draw conclusions about Cuban or 
other Hispanic outcomes . 



179 



Native Americans 

National data for American Indians and Alaska Natives indicate 
that birthweight distribution and neonatal mortality for Native 
Americans are quite good and have shown improvement over time. 
Unfortunately, postneonatal mortality is quite high. The reduction in 
postneonatal mortality should be a high priority. Special 
considerations for American Indian and Alaska Natives are the high 
rates of death from unintentional injuries and the possible influence 
of diabetes or alcohol use of the mother on perinatal outcome or 
postneonatal deaths (10). As with all populations, health education, 
living conditions and access to health care are especially important. 
Use of well baby care and the quality of sick baby care must be 
considered. 

Neonatal mortality rates and the birthweight distribution are 
favorable and have improved along with improvements in prenatal care 
for American Indians and Alaska Natives. These good outcomes are 
observed despite the relatively poor patterns of prenatal care among 
American Indians and Alaska Natives with far more women receiving late 
prenatal care or no prenatal care at all than among Whites. 
Birthweight has the predictable relationship with prenatal care--i.e., 
the earlier the care, the better the birthweight--but the level of 
care is depressed and birthweight is not. Clearly there is room for 
improvement in the receipt of prenatal care, but a number of questions 
are raised. 

Data problems, evident for other subgroups, are even greater for 
Native Americans. Diversity within the Native American population and 
likely changes over time in the proportion of American Indians who so 
declare themselves in official documents create special problems. The 
Indian Health Service data systems are an excellent beginning for 
understanding infant mortality, but additional data are highly 
desirable. 

Asian/Pacific Islanders 

The Asian/Pacific Islander population within the United States is 
quite diverse, and available data are often not adequate. In general, 
perinatal outcomes are good among Asian/Pacific Islander women with 
relatively low rates of low birthweight (6.5 percent). Chinese had 
the lowest rate (5.3 percent) and Filipinos the highest rate (6.9 
percent) of low birthweight. Asian/Pacific Islander mothers are less 
likely than White mothers to be teenagers (6 percent versus 12 percent 
among Whites) or unmarried (8.4 percent vs. 12.1 percent for Whites). 
Maternal education and socioeconomic status are relatively high among 
many Asians, and prenatal care patterns are good, with 75 percent 
beginning care in the first trimester. Southeast Asian refugees 



180 



present a somewhat different picture, with considerable variability 
and numbers too small to permit national estimates of rates. Some 
groups, for example the Hmong, have cultural patterns of very early 
childbearing that may place them at greater perinatal risk. 



OPPORTUNITIES FOR PROGRESS 

The following are highlights of the Subcommittee's deliberations 
regarding needs in the area of infant mortality: 

• Personal reproductive responsibility should be enhanced through a 
variety of channels, including enlarged content of health 
education for providers and lay audiences, improved family 
planning services, research on prevention of unplanned 
pregnancies, and the development of improved approaches to 
fertility regulation. Further research is needed on behaviors 
associated with unplanned pregnancies, including perceived risks 
and benefits of methods of fertility regulation. This is 
especially true for teenage women who constitute an important 
segment of the minority childbearing population. 

• Since many risks exist before pregnancy or are actualized early 
in pregnancy, steps should be taken to improve our ability to 
increase minority women's knowledge of risks during pregnancy and 
of the value of early and ongoing prenatal care. Research should 
elaborate the mechanisms by which the planning of pregnancies 
influences prenatal care and pregnancy outcome. Behavioral 
approaches to accurate dating of pregnancies should be explored. 

• Use of prenatal care is influenced by the availability and 
accessibility of services. Many minority women, especially 
teenagers, receive their care through Federal or State-subsidized 
services or must pay for their own care. It is important to 
lower barriers created by coverage patterns for high-risk women 
low physican participation in Medicaid; problems with processing 
claims/eligibility quickly; caring for women who move during 
pregnancy; and others. 

• Provision of technical assistance to State Title V agencies and 
other providers of care for mothers and infants interested in 
trying innovative approaches to funding care programs. Continue 
to monitor changes in expanded eligibility resulting from the 
Child Health Assistance Program (CHAP) in terms of 
characteristics of new eligibles, use of care and outcomes. 

• High-risk women often need a larger array of services than 
others, and minority women are often high risk. The Subcommittee 
recommends ways to address these needs through expanded nutrition 
supplements, health education services, provider and patient 
education regarding risk assessment, and recognition of preterm 
labor and removal of arbitrary limits to services. 



181 



• Special attention should be given to aspects of prenatal care 
designed to identify women at risk of preterm labor. Presently 
there are innovative programs designed to identify and treat 
women at risk of preterm labor. These programs should be 
evaluated and considered for replication. Similarly, 
regionalization of care for women at high risk has been valuable 
and should be maintained. 

• Although it is clear that early prenatal care is valuable, it is 
also clear that more should be known about how the specific 
components of care influence women's likelihood of coming for 
care and the effect of that care. Research is needed on the 
other health-related behaviors women may engage in during 
pregnancy that are related to pregnancy outcome but not 
necessarily a part of typical prenatal care. Special attention 
should be given to improving techniques to help pregnant women 
stop smoking. 

• A number of conditions can be screened during pregnancy and 
knowledge of identified risks can then influence treatment or 
type of care. For example. Black women are at increased risk of 
bearing twins, and multiple pregnancies are high risk for early 
labor and adverse outcome; recent immigrants, especially Asians 
and those from parts of the developing world, are at risk of 
hepatitis B which affects the neonate and creates a carrier pool. 
Screening for such conditions is important to secure optimal 
care. 

• A number of areas require improved research and attention by 
health providers, such as the role of stress, type of employment, 
transportation problems, and nutrition on pregnancy, the use of 
prenatal care and pregnancy outcome. Comprehensive health 
education for providers and information campaigns for the public 
could address avoidable health risks during pregnancy. 

• A model state brochure should be developed for low-income 
pregnant women describing simply how and where to obtain Medicaid 
eligibility, the need for early care, avoidable risks to the 
fetus (e.g., smoking), and a list of providers accepting Medicaid. 
Assure that the message is delivered to high-risk groups in 
culturally appropriate forms. 

• The Federal Government should continue to review and sponsor 
mechanisms to aid in local and state investigations of infant 
deaths in areas of high or changing infant mortality rates. 

• The Department should coordinate with the American College of 
Obstetricians and Gynecologists and other professional organiz- 
ations to review the influence of malpractice insurance on Medicaid 
participation and to seek an appropriate vehicle for assessing 

the role of uncompensated care in influencing pregnancy outcome. 



182 



Assess evaluations and consider replication of innovative models 
of active follow-up programs to support families of infants at 
high risk of postneonatal disease. Support groups in other 
disease areas have had documented successes. Their value in 
regard to assisting parents of high-risk infants should be 
evaluated. 

Many postneonatal deaths are due to injury. The recent 
improvements in seat belt protection for children and childproof 
containers should serve as a model for preventing other sources 
of accidental death for infants. The 1990 Objectives for the 
Nation which have focused attention to the role of seat belts in 
child safety, and other areas (such as death from burns) could be 
considered at the mid-decade review. 

To understand better the interplay of social, biological and 
environmental factors associated with low birthweight and the 
relationship of low birthweight to infant mortality among 
minority groups, research should address birthweight-specif ic 
mortality rates for minority groups, investigate the role of 
nutrition or generational effects as an influence on the 
relatively high low birthweight rates for apparently low-risk 
Black women, and attempt to verify and explain the apparently 
favorable birthweight distributions found among Mexican American 
and Native American women. 

Research on the perinatal period has paid far less attention to 
the factors associated with postneonatal mortality. It is 
recommended that research be increased and directed at the 
preventable causes of postneonatal mortality, including the 
interrelationship of individual and familial behaviors, health 
care delivery factors, use of well and sick-baby care; 
immunizations for babies, and sources of accidental death such as 
risks associated with substandard housing. 

Research is needed on the link between economic conditions and 
infant mortality to specify better the interplay between the 
individual, financing differences, and structural factors. 
Expanded research on economic aspects of infant mortality in 
conjunction with sociocultural factors may help explain the 
relatively good outcomes experienced by Asian/Pacific Islanders 
and Native Americans. 

Most of the large programs, like Maternal and Infant Care (MIC), 
Improve Pregnancy Outcome (IPO), and the Special Supplemental 
Food Program for Women, Infants, and Children (WIC) have only 
partially been evaluated. More complete evaluations of these 
programs should be undertaken. Evaluation techniques have not 
kept pace with the programs; specific recommendations for 
strengthening evaluations are made in the Subcommittee report. 



183 



Evidence is accumulating to document the value of nutrition 
programs (such as WIC). Continued research and implementation 
should be considered. 

• States should be encouraged to modify their birth and death 
certificates to include better identification of ethnic groups, 
especially Hispanics (already available on the certificates from 
22 states). Furthermore, the addition of certain new items of 
information on the birth certificate (such as smoking, 
prepregnancy weight and height, and insurance coverage, and so 
forth) could be extremely beneficial in monitoring and studying 
the factors that influence pregnancy outcome. 

• The National Infant Mortality Surveillance project done by CDC in 
collaboration with NICHD, HRSA, NCHS and the State vital 
registrars is developing a national data base of linked birth and 
death records for 1980 that will provide valuable data for 
analyzing infant mortality. The extension of this project to a 
linked birth and death record for all births and infant deaths is 
planned by NCHS. It is strongly recommended that this project 
begin with the 1982 birth cohort and be continued. 

• Much of the evaluative research on infant mortality interventions 
was undertaken before some major changes in the U. S. 
demographics, poverty populations, financing shifts and changes 

in treatment systems . It is recommended that more contemporary 
data collection and prospective studies be undertaken. Data 
should be disaggregated by race and ethnicity, providing detail 
within major ethnic groups such as Hispanics, and adequate cases 
for comparison of adolescent with nonadolescent mothers. 

• Data on insurance coverage of women and infants should be 
improved, especially in regard to those eligible and receiving 
Medicaid. These data could aid in our understanding of the role 
of financing and service delivery issues regarding infant 
mortality. 

• Several national data bases (e.g., the National Natality Survey, 
the National Survey of Family Growth, and the National 
Longitudinal Survey- -Youth Cohort) include rich data regarding 
pregnancy outcome. Improvements are recommended to enhance their 
value in regard to increasing knowledge of infant mortality/low 
birthweight for minorities and for research on teenage 
childbearing. 

• Research on some ethnic groups (e.g. , Indochinese refugees) will 
be better served by data collection and research efforts directly 
addressing their health concerns, rather than oversampling in 
multipurpose surveys. In other cases, valuable data sets exist 
regarding specific minority groups and could receive further 
analysis, e.g., the Puerto Rican Fertility Survey or Indian 
Health Service data. 



184 



The opportunities summarized above point to issues in education, 
information, research, and services where advances could be made. 
Infant mortality is a complex problem with many medical and 
nonmedical aspects. There are no simple solutions, but there are 
many things that we know about fertility, pregnancy and infant care 
that can help address the problem of infant mortality, a problem that 
takes a disproportionate toll on minorities. 



185 



REFERENCES 



1. National Center for Health Statistics. (1984, September 21). 

Annual summary of births , deaths , marriages , and 
divorces: United States, 1983 . Monthly Vital 
Statistics Report 32(13). Hyattsville, MD: Author. 

2. National Center for Health Statistics. (1984, December). 

Health, United States, 1984 (DHHS Publication No. (PHS) 
85-1232). Hyattsville, MD: Author. 

3. Wallace, H. M. , Goldstein, H. , & Erickson, A. (1982). Comparison 

of infant mortality in the United States and Sweden. Clinical 
Pediatrics , 2j., 156-162. 

4. McCormick, M. C. (1985). The contribution of low birth weight to 

infant mortality and childhood morbidity. New England 
Journal of Medicine , 312 , 82-90. 

5. National Center for Health Statistics. (1984, September 28). 

Advance report of final natality statistics: United States, 
1982. Monthly Vital Statistics Report , 33(6), Supplement. 

6. National Center for Health Statistics. (1984, December 20). 

Advance report of final mortality statistics: United States 
1982. Monthly Vital Statistics Report , 22(8), Supplement. 

7. National Center for Health Statistics. (1984). Vital Statistics 

of the United States, 1979, Volume lI--Mortality , 

Part A (DHHS Publication No. (PHS) 84-1101). Hyattsville, 

MD : Author . 

8. Markides, K. S., & Hazuda, H. P. (1980). Ethnicity and infant 

mortality in Texas counties. Social Biology , 27, 261-271. 

9. Williams, R. L. , Binkin, N. J. , & Clingman, E. (in press). 

Pregnancy outcomes among Hispanic women in California. 
American Journal of Public Health . 

10. Indian Health Service. (1984, June). Indian Health Service 

chart book series (No. 421-166:4393). Washington, DC: 
U.S. Government Printing Office. 



186 



HEALTH SERVICES AND RESOURCES FOR MINORITIES 



Introduction 

The health status differences observed among U.S. population 
groups are in part related to the health care resources and services 
available to individuals. Some of the factors that cut across 
disease-related areas and affect health status patterns are: health 
services' utilization; health care financing; availability of health 
care facilities and personnel; health knowledge and behavior; and the 
influence of health education on health knowledge and behavior. The 
Task Force examined these factors and analyzed, where possible, their 
impact upon the health of minorities. 

Access, Utilization, and Financing 

National surveys measuring current health care utilization 
indicate that minority populations receive health care services at 
levels similar to those of nonminorities ; differences, however, in the 
patterns of utilization remain. The large differences in gross 
indicators of health care access and utilization, such as number of 
visits to a physician, that existed between nonminority and minority 
populations have diminished since the creation of Medicaid and 
Medicare. Both of these important health-financing programs have 
enabled large segments of disadvantaged and older minorities to gain 
access to needed health care. However, the poor health status 
observed in many minority groups and differences remaining between 
minorities and nonminorities in types of care and financing, suggest 
that minorities still have poorer access to and use of comprehensive 
and high-quality health care. 

Detailed national-level data describing the health service 
patterns of U.S. minority populations are not available. The minority 
groups for whom the most health information is available are Blacks 
and, to a lesser extent, Hispanics . Data describing Hispanic 
subgroups are limited and generally obtainable only through combining 
several years of national survey data or through small studies. 
Comprehensive data on the health service patterns for many Native 
Americans are not available. Although the Indian Health Service (IHS) 
data describe the extent and nature of the services provided, 
it serves only those residing on or near reservations, approximately 
60 percent of the American Indian and Alaska Native population (") . The 



Calculations are based on the following formula: 

1980 Census = 1.5 million American Indians and Alaska Natives 
IHS service population = 888,000 (i.e., 59 percent of total) 
Two-thirds live off the reservation. 



187 



Asian/Pacific Islander population includes many subgroups that differ 
in cultural characteristics, health needs, and health care patterns. 
Because few sources identify subgroups and because Asian/Pacific 
Islanders account for less than 2 percent of the U.S. population, 
very little information about health services to this minority 
and its subgroups exists. Most data on Asian/Pacific Islanders 
reflect dominant subgroups such as the Chinese, Japanese, and 
Filipinos. The following discussion, therefore, concentrates on 
information relating to Blacks and, when available, other minorities. 

Use of Health Professionals 

From 1978 to 1980, the National Health Interview Survey, reported 
4.7 as the average annual number of physician visits per person in 
this country. The number of visits was similar for Black, Hispanic, 
and White populations, although Mexican Americans, at 3.7 had a 
noticeably fewer visits. When these data are examined by age, 
however, more pronounced differences in utilization patterns emerge. 
The average annual number of physician visits for minority children is 
fewer than for White children. On the average. White children under 
age 17 visit a physician 4.5 times each year compared to 3.5 for 
Hispanic children and 3.2 for Black children (1). Vaccination rates 
among children, an important indicator of the use of preventive health 
measures, also show differences. Sixty-seven percent of White 
children, one to four years old, were vaccinated against measles in 
1983 compared with only 57 percent of minority children (2). 

A clear pattern of lower use of preventive health services is 
seen among minority adult populations. Nearly eight out of ten White 
women seek prenatal care during the first trimester of pregnancy 
though only six out of every ten Black women seek this care. Except 
for Cuban women, rates of prenatal care in the first trimester among 
Hispanics women from the 22 States that report Hispanic origin are 
lower than those of Black women; rates for Native American women are 
among the lowest of any racial or ethnic group in the United States. 
Asian/Pacific Island women, as a group, have levels of first trimester 
prenatal care similar to those of White women (2); however, rates vary 
significantly between the different subgroups. Unfortunately, 
detailed national information about screening and diagnostic services 
received by different population groups is not available. Limited 
studies indicate that nonminorities receive more cancer-screening 
tests, breast examinations, prostate palpations, and proctoscopies 
than do minorities (3) . 

Dental services are used less frequently by minority populations 
than by nonminorities. From 1978 to 1980, 56 percent of Whites 
reported visiting a dentist in the previous year compared with 37 
percent of Blacks. Hispanics also visited dentists less frequently 
than Whites. Among Hispanic subgroups, Mexican Americans, at 35 
percent, had the lowest percentage of dental visits in the previous 
year (1). Forty-eight percent of Asian/Pacific Islanders and 40 
percent of Native Americans (4) reported visiting a dentist during the 



188 



previous year. The lower use of dental services by minority 
populations begins in childhood; 68 percent of White children, ages 4 
to 16 years, were reported to have seen a dentist in the previous 
year. The rate was 44 percent for Black children, ages 6 to 14 years, 
and 39 percent for Mexican American children (1). 

Sources of Care 

Having a usual source of medical care has been found to be a good 
predictor of use of health services and suggests a greater continuity 
of care, associated with improved health outcomes. A 1977 study of 
national medical care behavior reported that 13 percent of Whites have 
no usual source of medical care; 20 percent of Blacks and 19 percent 
of Hispanics reported this (5). 

Continuity of health care is related to the location of medical 
service. There is greater continuity of care when patients are able 
to revisit the same provider. Seventy percent of the White population 
reported using a physician's office as their usual source of care 
compared with 54 percent of Hispanics and 46 percent of Blacks. Twice 
as many Blacks and Hispanics as Whites reported hospitals and health 
clinics as their usual source of medical care (5). The widespread use 
of hospitals and public health clinics for medical care by Blacks also 
was documented in the 1980 NHIS. In that year, 25 percent of all 
visits to physicians made by Blacks occurred in hospital clinics or 
emergency rooms compared with 11 percent by Whites (6). 

The same survey also revealed differences in the patterns of 
hospital utilization by minority groups. From 1978 to 1980, Blacks 
reported hospital stays that averaged two days longer than those of 
Whites (11 days versus 9 days). The average hospital duration for 
Hispanics was slightly shorter than that for Whites (1). 

Ability to Pay for Services 

A prerequisite for access to medical care is the ability to pay 
for services, which in turn largely depends on income and health 
insurance. The median income for all Black and Hispanic families is 
substantially lower than for White families resulting in less 
disposable income available for the direct and indirect purchase of 
health care. Family income for Asian/Pacific Islanders, however, is 
not low, due in part to living patterns in which several wage-earning 
adults live in the same household, although their individual wages may 
be low. Viewing the Asian/Pacific Islander household income only on a 
national average level masks subpopulation differences and the wide 
diversity of income levels. 

Health Insurance 

Payment for health services is generally made through some form 
of health insurance. Although a survey conducted in 1982 by the 
Robert Wood Johnson Foundation found that only about nine percent of 



189 



the American population had no health insurance coverage of any kind. 
Black and Hispanic groups had noninsurance rates that were two to 
three times higher than Whites (7) . Recent systematic information 
about the insurance status of Asian/Pacific Islanders and American 
Indians and Alaska Natives living outside IHS service areas is not 
available. The predominant source of funding for health care for 
those under 65 years old in the United States is employment -based 
third-party health insurance. However, because most minorities 
experience higher unemployment rates, fewer minorities can obtain this 
kind of health insurance (8). 

Medicaid has become an important source of health insurance for 
many minorities. The 1982 Robert Wood Johnson survey found that 20 
percent of Blacks and 13 percent of Hispanics use Medicaid as their 
only source of health insurance (7). 

Although Medicaid has enabled many minority families to have 
access to medical care, reimbursement schedules limit the range of 
available health services, and frequent changes in program eligibility 
tend to disrupt the continuity of health care. 

In addition to Medicaid, funding for medical services for 
refugees is available through Title XIX State medical programs. This 
program particularly affects several of the Asian/Pacific Islander 
populations. During their first 18 months in this country, most 
Southeast Asian refugees are covered by Medicaid or receive medical 
help through Refugee Medical Assistance. 

Having some form of health insurance is related to using health 
services and to whether people report having a usual source of medical 
care (9). Twenty-five percent of the medically uninsured report 
having no usual source of care compared to only 13 percent of those 
covered by private insurance, 11 percent of those covered by Medicare, 
and 15 percent of those enrolled in Medicaid (5) . 

The continuity of health insurance, generally defined as the 
proportion of the year a person is covered by health insurance, is 
related to employment status and to changes in Medicaid eligibility, 
and has an impact upon health care utilization. Greater proportions 
of minority groups are without insurance for some portion of the year 
than are the nonminority population. Those with less continuity of 
health insurance use health services less frequently than those who 
are insured all year round (9). 

Though all Americans 65 years of age or older are covered by 
Medicare, it does not provide full reimbursement for all health care 
needs. The White population supplements Medicare with private 
insurance twice as often as does the Black population (69 percent 
versus 31 percent) (10). Although data are sparse, an analysis of 
Medicare utilization information in 1978 revealed that more Whites 
than non-Whites were reimbursed for physician and other medical 
services (597 per 1,000 of enrolled Whites versus 521 per 1,000 



190 



enrolled non-Whites). Reimbursement amounts per person served that 
year also appear to be more for Whites ($373) than for non-Whites 
($348) (11). 

Knowledge of the health care utilization and access patterns of 
minority populations is fragmented, because little or no information 
is available for minority population subgroups. More data on these 
populations is needed for a fuller understanding of the health care 
services they are actually receiving and need. 

Health Professionals 

One of the key elements of quality health care is the 
availability of well-trained health care providers. The degree to 
which the availability of these professionals differs between minority 
and nonminority groups may play a crucial role in reducing disparities 
in overall health status. The Task Force compiled and analyzed data 
on the distribution of health personnel in counties where at least 20 
percent of the population consists of a single minority (12). Although 
analyses indicate that some counties with a high density of Blacks, 
Hispanics, and Asian/Pacific Islanders had numbers of health care 
professionals at least equal to the number located in areas with a 
lower proportion of minorities, this "index of availability" of care 
may be misleading. County-wide distribution of physicians and other 
health care professionals does not reveal practice patterns, 
accessibility, or actual availability of those professionals to 
individual minority communities. Furthermore, since many of the 
counties analyzed are urban, this information may simply reflect the 
tendency for health care professionals to cluster in cities. 
County-level analyses of physician distribution, for example, do not 
indicate the number of professionals who accept Medicaid/Medicare 
payments or whose practices might be located in minority areas. Many 
areas with larger numbers of professionals also tend to be those with 
medical schools or other institutions whose teaching staff are 
not available as practitioners. Thus, the truly available resources 
for minority health care may be considerably less than implied by 
statistics . 

Existing studies suggest that health professionals who are from 
the same cultural background as their patients may be able to 
communicate better with their patients and thereby have a positive 
influence on many of the factors that affect health outcome. 
However, with some notable exceptions among selected subgroups of 
Hispanics and Asian/Pacific Islanders, minorities are substantially 
underrepresented among students and practitioners of virtually all 
major health and allied health professional disciplines (13). 
Most minorities receive health care from providers who do not share 
their own ethnic/cultural background. 



191 



Minorities are also underrepresented in research and teaching 
positions in health sciences. An insufficient number of role models 
and teachers who are sensitive to the training needs of minorities has 
a negative effect upon the training of future minority health 
professionals . 

Although data are limited on the number, distribution, and practice 
patterns of specific minority health professionals, current information 
suggests the following: 

• The proportion of Blacks among health professionals is 
relatively low and not likely to change appreciably in the near 
future. In virtually none of the States surveyed for this report 
do the number of Black graduates of medical, dental, or pharmacy 
schools even approach the proportions of Blacks in the 
population. If the number of Black graduates continues to 

rise, as it has during the past two decades, it is still 
unlikely that the proportion of Black professionals will 
significantly increase in the near future. 

• Studying the distribution of health professionals within the 
Hispanic population is particularly difficult because of the 
various subpopulations in this group. Nonetheless, Mexican 
Americans and Puerto Rican living in the U.S. appear to be 
significantly underrepresented in the health professions. 
Generally, Hispanic health care providers are unevenly distributed 
among Hispanic communities. 

• Asian/Pacific Islanders, as a group, appear to be dispropor- 
tionately overrepresented among health professionals in training 
and in private practice. However, data for identifying the 
distribution of health professionals within Asian/Pacific 
Islander subgroups are not readily available nor are data 
identifying that proportion of Asian/Pacific Islander health 
care providers which cares for Asian/Pacific Islander patients. 

• Many American Indians and Alaska Natives receive health care 
through the Indian Health Service, a health delivery 
system created for the purpose of meeting their health needs. 
The IHS is attempting to make greater use of indigenous health 
workers and to tailor services more closely to individual 
tribal needs. However, for American Indians and Alaska Natives 
not living on or near reservations--nearly two-thirds of the total 
population- -the scarcity of American Indian and Alaska Native 
health providers becomes problematic when cultural differences 
affect access to care. 



192 



Health Education and Information 

The higher rates of the incidence and prevalence of certain 
health conditions for minority populations is a compelling reason to 
identify ways in which the health status of minorities can be improved 
through health education interventions. Data have clearly illustrated 
that each of the six priority areas that contribute significantly to the 
disparity in health status has components or controllable risk factors 
that are amenable to health education efforts. Such factors include 
the use of tobacco, the maintenance of healthful dietary practices, 
and the management of stress (14). 

Behavioral, social, cultural, and ethnic variables that exist 
within minority populations may affect the delivery of health 
information to a significant degree and should be considered when 
designing a health education intervention. Although some similarities 
do exist within a minority group or between minority groups, 
differences in such aspects as educational level, socioeconomic 
status, and religion should be examined for their potential impact on 
the design and implementation of a health education program. A common 
characteristic found in each of the four minority groups addressed by 
the Task Force is the important role played by the family in 
disseminating health information and in providing support to assist 
the individual in complying with a prescribed health action (15). It 
remains difficult, however, to identify those specific behavioral 
and/or cultural variables that affect health behavior within each 
minority population because of the limited amount of research 
concerning minority health beliefs, attitudes, and practices. 
Clearly, additional data are needed in this area to tailor health 
education programs more carefully to the needs of minorities. 

Health education interventions for the four minority groups 
identified should be directed at improving the awareness of 
individuals and communities about controllable risk factors associated 
with the causes of excess death and disability (16). Such measures 
can occur in a number of settings--schools , worksites, medical care 
facilities, and communities. Health education activities should 
foster the development of lifestyles that maintain and enhance the 
state of health and well-being as well as increase public and 
professional awareness of risk factors that affect minority health 
status . 

Variables that affect the development and implementation of a 
health education intervention include the nature of the target 
population, the types of interventions available, and the kinds of 
outcomes to be expected--health or otherwise (17). Above all, the 
educator must understand the critical problems, the likely delivery 
mechanisms, and the strategies for implementation. 



193 



Specific priority health behaviors, among the most important in 
minority populations and most likely to be affected by health 
education interventions include: smoking, diet and nutrition, social 
support behaviors, exercise, alcohol and drug misuse, maternal and 
child health issues, safety issues, stress management, sexually 
transmitted diseases, and teenage pregnancy. 

Because so many factors can enhance or impede the effectiveness 
of a health education strategy, it is important to consider the 
factors that contribute to making a hef.lth message and its 
dissemination special for a given population. Such factors might 
include the influence of community leaders and groups, the community's 
attributes, an individual's perception of barriers to care and to 
engaging in a specific health action, the environment, demographic 
parameters, the nature of the innovation, and the channels available 
for communication. 

Differences in health status underscore the importance of 
providing health education to minority populations; however, consensus 
has not been reached on how best to develop health education programs 
and strategies, how to effect change, and how to disseminate these 
strategies. Therefore, efforts need to be expanded or initiated to 
elucidate those factors that contribute to the design, implementation, 
and diffusion of successful health education interventions in all 
minority populations and subgroups in the United States. 

Conclusion 

Differing patterns of health services' utilization, health 
insurance coverage, access to health providers, and the availability 
of appropriate health education materials and programs contribute to 
the disparity in health status between minority and nonminority 
groups. Further study and identification of specific ways to improve 
minority access to each of these health resources is essential to 
improving the health status of minority groups in the United States . 



194 



REFERENCES 

1. Trevino, F. M. , & Moss, A. J. (1984, December). Health 

indicators for Hispanic, Black, and White Americans 
(DHHS Publication No. (PHS) 84-1576). Vital and Health 
Statistics, Series 10, No. 148. Hyattsville, MD: National 
Center for Health Statistics. 

2. National Center for Health Statistics. (1984, December). 

Health, United States, 1984 (DHHS Publication No. (PHS) 
85-1232). Washington, DC: U.S. Government Printing Office. 

3. Warnecke, R. B. (1981). Intervention in Black populations. In 

C. Mettlin, & G. Murphy (Eds.), Cancer among Black 
Populations . New York, NY: Alan R. Liss, Inc. 

4. National Center for Health Statistics' Health Interview Survey, 

data cited in Gerzowski and Adler, Health Status of Native 
Americans . Unpublished manuscript. 

5. Kasper, J. A., & Barrish, G. (1982). National health care 

expenditures' study. Data preview 12: Usual sources 
of medical care and their characteristics (DHHS 
Publication No. (PHS) 82-3324). Washington, DC: National 
Center for Health Services Research. 

6. Collins, J. G. (1983, June). Physician visits, volume, and 

interval since last visit. United States, 1980 (DHHS 
Publication No. (PHS) 83-1572). National Center for 
Health Statistics. Washington, DC: U.S. Government Printing 
Office. 

7. Butler, J. (1983). Updated report on access to health 

care for the American people . (Special report, V. Weisfeld, 
Ed.) Princeton, NJ: The Robert Wood Johnson Foundation. 

8. Trevino, F. , & Moss, A. (1983). Health insurance coverage and 

physician visits among Hispanic and non-Hispanic people. In 
Health, United States, 1983. (DHHS Publication No. (PHS) 
84-1232). Washington, DC: U.S. Government Printing Office. 

9. Wilinsky, G. R. , & Walden, D. C. (1981, November). Minorities, 

poverty, and the uninsured. Paper presented at the 109th 
annual meeting of the American Public Health Association, 
Los Angeles, CA. 

10. Cafferata, G. L. (1984). National health care expenditures' 

study. Data Preview 18: Private health insurance 
coverage of the Medicare population (DHHS Publication 
No. (PHS) 84-3362). Washington, DC: National Center for 
Health Services Research. 



195 



11. Muse, D., & Sawyer D. (1982, April). The Medicare and 

Medicaid data book, 1981 . Department of Health and 
Human Services, Health Care Financing Administration, Office 
of Research and Demonstrations. Washington, DC: U.S. 
Government Printing Office. 

12. Report of the Working Group on Health Professionals . (1985). 

Unpublished manuscript. Task Force on Black and Minority Health, DHHS. 

13. Bureau of Health Professions. (1984). Minorities and women 

in the health field, 1984 (DHHS Publication No (HSRA) 

HRS-DV 84-5). Washington, DC: U.S. Department of Health and 

Human Services. 

14. U.S. Department of Health and Human Services. (1979). Healthy 

people: The Surgeon General's report on health promotion 

and disease prevention (DHEW (PHS) Publication No. 79-55071). 

Washington, DC: U.S. Government Printing Office. 

15. National Heart, Lung, and Blood Institute. (1984). Development 

of diffusion strategies among culturally diverse populations 
(NIH Publication No. 84-2697). Washington, DC: U.S. Department 
of Health and Human Services. 

16. Office of Disease Prevention and Health Promotion. (1981). 

Strategies for promoting health for specific populations 
(DHHS Publication No. (PHS) 81-50169). Washington, DC: 
U.S. Department of Health and Human Services. 

17. Kolbe, L. , &. Iverson, D. (1984). Comprehensive school health 

education programs. In J. D. Matarazzo, S. M. Weiss, J. A. Herd, 
N. E. Miller, & S. M. Weiss (Eds.), Behavioral health: A handbook 
of health enhancement disease prevention . New York, NY: 
John Wiley and Sons. 



196 



Inventory of DHHS 
Program Efforts 

Survey of Nonfederal 
Organizations 




INVENTORY OF DHHS PROGRAM EFFORTS IN MINORITY HEALTH 

An inventory of Department of Health and Human Services' program 
efforts in minority health was compiled to provide the Secretary and 
the Task Force with a comprehensive description of all programs, 
current or planned, that relate specifically to minority populations. 
This information was used by the Task Force in the recommendation 
development process to ensure that the suggested activities would 
provide new directions to existing departmental initiatives. The 
inventory also will be useful to organizations and individuals 
actively involved with minority health issues. 

The inventory obtained information from the following agencies: 

Alcohol, Drug Abuse, and Mental Health Administration 

Centers for Disease Control^ 

Food and Drug Administration 

Health Care Financing Administration ^ . 

Health Resources and Services Administration . 

National Institutes of Health, 

Office of the Assistant Secretary for Health 

Office for Civil Rights 

Office of the Secretary v 

Office of Human Development Services 

Social Security Administration. 

The program descriptions were based on those data maintained in 
each agency's data management system; they varied greatly in the 
amount of detail provided. Although the inventory originally was 
intended to identify programs that focused on minority populations 
specifically, it was found that many programs benefitted all 
populations, including minorities. In some instances, it was possible 
to identify the extent of activities targeted to minorities; for 
others it was difficult to separate minority-specific components from 
the overall program. It is important to note that this compilation of 
DHHS programs and projects represents the first such grouping of 
departmental activities in the area of minority health. 

Ouestionnaire Development 

A four-page questionnaire was developed requesting 
program- level officers to indicate whether their programs addressed the 
following areas: cancer; cardiovascular and cerebrovascular disease; 
diabetes; arthritis and other musculoskeletal disorders; nutrition; 
disease and disorders of the eye; infectious diseases; digestive 
disorders; genetic disorders; infant mortality and maternal health; 
homicide, suicide and unintentional injuries; chemical dependency and 
related diseases; mental health and illness; occupational health; 
respiratory diseases; dental health; kidney disorders; or some other 
disorder . 



197 



Another series of questions requested descriptions of programs 
and how each program addressed minority health issues. The major 
classes of activity were: health service delivery, research and data 
collection, health professions' development, and health 
educat ion/ inf ormat ion diss eminat ion . 

Overall, the questionnaire attempted to gauge the extent of 
existing programs that addressed the minority health concerns. 

Data Collection 

Inventory questionnaires were distributed to the major components 
of DHHS : the Assistant Secretary for Health, the Assistant Secretary 
for Human Development Services, the Administrator for the Health Care 
Financing Administration, and the Commissioner of the Social Security 
Administration who, in turn, distributed them to their respective 
operating divisions. Instructions were provided that explained the 
purpose of the survey and the required information. Meetings were 
held with each agency contact to explain the nature of the Task Force 
and answer questions. More than 195 questionnaires were submitted by 
the agencies. Each questionnaire was reviewed for clarity and 
completeness by Task Force staff. 

Data Analysis and Reporting 

The program descriptions reflect the broad diversity of the 
programs administered by DHHS. Although some submissions focus on 
broad research issues that, by their very nature, included minority 
health issues, others focused on model demonstration programs that 
target specific minority groups. To preserve the richness of the 
descriptions, no attempt was made to combine the material into broader 
classifications . 

Index of DHHS Programs 

The index that follows lists either agencies or institutional 
components that have ongoing or planned minority-related initiatives. 
Complete descriptions of every program appear in another volume of 
this report. The office address and telephone number of each program 
are included in the later volume so that future users may readily 
obtain additional information. 



198 



ALCOHOL, DRUG ABUSE, AND MENTAL HEALTH ADMINISTRATION 
(ADAMHA) 

National Institute of Alcohol Abuse and Alcoholism: 
Division of Biometry and Epidemiology 
Black and Hispanic Alcohol Problems: A National Study 

National Institute on Drug Abuse: 
National Drug Abuse Media Campaign 
Ethnic Community Initiative 
NIDA Starter Award 

Minority Access to Research Centers 

Prevention of Drug Abuse Among Minority Populations 
Treatment of Drug Abuse Among Minority Populations 
Ethnic Minority Family Mobilization Project 
Estimating Mental Health Need 

National Institute of Mental Health: 
Prevention Program 

Center for Studies of Mental Health of the Aging 
Center for Studies of Minority Group Mental Health 
Center for Studies of Antisocial and Violent Behavior 
Center for Prevention Research 

Center for Mental Health Studies of Emergencies 
Center for Epidemiologic Studies 
Mental Health Clinical Research Centers 
Research Scientist Development 
NIMH Minority Biomedical Research Support 
Clinical Research Branch 
Small Grant Program 
Psychosocial Treatments Research 

Child and Adolescent Service System Program (CAASP) 
Community Support Program 
National Research Service Award 
Mental Health Clinical Training 
National Reporting Program 

CENTERS FOR DISEASE CONTROL (CDC) 

Investigations and Technical Assistance 

Injury Prevention 

Occupational Safety and Health - Training Grants 

Occupational Safety and Health - Research Grants 

Childhood Immunization Grants 

Health Programs for Refugees 

Venereal Disease Control Grants 

Venereal Disease Research, Demonstration, and Public Information 

and Education Grants 
Project Grants and Cooperative Agreements for Tuberculosis Control 

Programs 
Cooperative Agreements for State-Based Diabetes Control Programs 



199 



FOOD AND DRUG ADMINISTRATION (FDA) 

Food Safety 

Nutrition 

Task Force to Increase Interaction with Minority Health Professional 

Schools 
Office of Consumer Affairs Communications 
Consumer Affairs Education Program (Field Offices) 

HEALTH CARE FINANCING ADMINISTRATION (HCFA) 

Medicare 

End-Stage Renal Disease Program 

Medicaid 

Research and Demonstration 

HEALTH RESOURCES AND SERVICES ADMINISTRATION (HRSA) 

Indian Health Service 

Community Health Center Program 

Black Lung Clinics 

Migrant Health Program 

National Health Service Corps 

Home Health Services Program 

National Health Service Corps Scholarship Program 

Hansen's Disease Program 

Health Careers Opportunity Program 

Advanced Financial Distress 

Nursing Special Project Grants 

Professional Nurse Traineeship Grant Program 

Area Health Education Centers 

Health Professionals Analytical Studies and Reports 

Nurses Midwifery Office 

Contract Health Service 

NATIONAL INSTITUTES OF HEALTH (NIH) 

Division of Research Resources: 
Animal Resources Program 
Biomedical Research Support Program 
General Clinical Research Centers Program 
Biomedical Research Technology Program 
Minority Access to Research Careers Program (MARC) 
Minority Biomedical Research Support Program (MBRS) 

National Cancer Institute: 

Epidemiology Research Program 

Chemical and Physical Carcinogenesis Research Program 

Biological Carcinogenesis Research Program 

Nutrition Research Program 

Tumor Biology Research Program 



200 



Immunology Research Program 
Diagnostic Research Program 
Preclinical Treatment Research Program 
Clinical Treatment Research Program 
Rehabilitation Research Program 
Comprehensive Minority Biomedical Program 
Resource Development Activities 
Cancer Control Program 

National Eye Institute: 

Retinal and Choroidal Diseases Branch 
Strabismus, Amblyopia, and Visual Processing 
Intramural Research Program 
Anterior Segment Diseases Branch 

National Heart, Lung, and Blood Institute: 
Heart and Vascular Diseases Program 
Lung Diseases Program 
Blood Diseases and Resources Program 
Companion Issues 

National Institute on Aging: 
Behavioral Sciences Research 
Systolic Hypertension in the Elderly 
Public Information Office 

Epidemiology, Demography, and Biometry Program 
Gerontology Research Program 

National Institute of Allergy and Infectious Diseases: 
Microbiology and Infectious Diseases Program 
Immunology, Allergic and Immunologic Diseases Program 

National Institute of Arthritis, Diabetes, and Digestive and Kidney Diseases 
Arthritis, Musculoskeletal, and Skin Diseases 
Diabetes 

Digestive Diseases and Nutrition 
Kidney, Urologic, and Hematologic Diseases 
Pima Indian Studies 

National Institute of Child Health and Human Development: 
Center for Research for Mothers and Children 
Healthy Mothers, Healthy Babies Program 
Center for Population Research 
Intramural Program 

National Institute of Dental Research: 
Office of the Director 
Extramural Programs 



201 



National Institute of General Medical Sciences: 
Pharmacological Sciences Program 

National Institute on Neurological and Communicative Disorders and Stroke: 
Travel Fellowships for Minority Neuroscientists 

Survey of Major Neurological Disorders in Copiah County, Mississippi 
Chronic CNS Disease Studies: Slow, Latent, and Temperate Virus Infection 
Summer Research Fellowship Program 

OFFICE OF THE ASSISTANT SECRETARY FOR HEALTH (OASH) 

National Center for Health Statistics: 
National Hospital Discharge Survey 
National Health and Nutrition Examination Survey 
NHANES I Epidemiologic Follow-up Survey 
Hispanic Health and Nutrition Examination Survey 
National Medical Care Utilization and Expenditure Survey 
National Ambulatory Medical Care Survey 
National Nursing Home Survey 
National Master Facility Inventory 
Vital Statistics Follow-back Survey Program 
National Vital Statistics Program 
National Survey of Family Growth 
National Health Interview Survey 

Office of Public Affairs: 

Healthy Mothers, Healthy Babies Coalition 

Information and Education on Acquired Immune Deficiency Syndrome 

Office of Disease Prevention and Health Promotion: 
National Health Promotion Program 
National Health Information Clearinghouse 
1990 Objectives for the Nation Initiative 
U.S. Task Force on Preventive Services 

Office of Refugee Health: 
Refugee Preventive Health 
Cuban/Haitian Entrant Program 
Health Program for Refugees 

Office of Population Affairs: 
Adolescent Family Life 
Office of Family Planning 



202 



OFFICE OF THE ASSISTANT SECRETARY FOR HUMAN 
DEVELOPMENT SERVICES (HDS) 

Administration for Native Americans 

Administration for Developmental Disabilities 

Administration for Children, Youth, and Families (Head Start) 

Coordinated Discretionary Funds Program 

Administration on Aging 

Title 111 of the Older Americans Act (Part B - Nutrition Services) 
Title VI, Older Americans Act, Grants to Indian Tribes for Supportive 
and Nutrition Services 

OFFICE OF THE ASSISTANT SECRETARY FOR PLANNING 
AND EVALUATION (ASPE) 

OFFICE FOR CIVIL RIGHTS, OFFICE OF THE SECRETARY (OCR) 

SOCIAL SECURITY ADMINISTRATION (SSA) 

Health-Related Programs 



203 



SURVEY OF NON-FEDERAL ORGANIZATIONS 
Introduction 

The Task Force conducted a nationwide survey of approximately 300 
individuals and organizations that represent health-specific 
professional, scientific, and service groups. The survey was intended 
to elicit information on ways the Department might improve the health 
status of minority Americans . 

The survey asked four questions: 

(1) From the perspective of your organization and the people you 
represent, what are the three most critical health disparities 
between minority and nonminority Americans? 

(2) For the disparities you identified, what appear to be the most 
significant contributing factors? 

(3) Highlighting specific examples known to your organization, 
what kinds of health programs in the minority community have 
been most successful? What has been the key element of that 
success? 

(4) Within the confines of the current Department of Health and 
Human Services' (DHHS) programs and policies, how might DHHS 
better address the disparity in the health status of minority 
populations? 

The following represents a summary of the 125 survey responses 
received by April, 1985. 

Summary of Responses 

The plight of many minority people in need of health care is 
captured in this excerpted comment: 

"Preventive care is often a luxury that time rarely affords 
minority people. One is inclined to ignore a cough, a lump in the 
breast, or even an advancing pregnancy when the demands of daily 
existence are overtaxing. These ceaseless demands for employment, 
housing, food, clothing, legal help, public assistance, etc., are 
sufficient to ensure that many illnesses or conditions reach a 
critical point before health care is sought." 

Socioeconomic issues influencing health status were frequently 
cited as contributors to the disparity. These included: the 
prevalence of poverty among minority groups, low income, unemployment, 
lack of health insurance, and inability to pay deductibles or 



205 



copayment costs of insurance. Another aspect mentioned frequently by 
respondents was the reduction in Government funding for health care 
services and programs for minorities. 

Many respondents believe that the major health disparities could be 
reduced through improved access to health care services and programs. 
These need to be designed and operated to be culturally sensitive to 
the specific minority population being served. The types of services 
most often advocated by respondents were health education and 
disease prevention programs. 

Suggestions for improving health care services and programs for 
minorities were: 

• Continued support for existing successful health programs. 

• Minority-specific research and data collection. 

• Prevention and health education programs that incorporate 
bicultural/bilingual services. 

• Minority participation in policy development. 

• Education and training programs. 

• Improved access to health care through modification of third- 

party payer systems . 

Specific Issues 

From the perspective of your organization and the people you 
represent, what are the three most critical health 
disparities between minority and nonminority Americans? 

For the disparities you identified, what appear to be the 
most significant contributing factors? 

The responses to the first two questions are reported together 
because of the linked nature of the majority of responses received. 
The most critical disparities identified by the respondents were in 
the areas of: 

• Access to health care. 

• Chronic diseases. 

• Pregnancy and birth disorders . 

• Availability of data. 



206 



Access to Health Care 

Problems concerning minority access to health care cut across all 
responses. Some respondents cited access to health services as a 
primary disparity, while others identified access as a secondary issue 
or a contributing facto:p to the primary disparities. For example, 
chronic disease conditions were often mentioned as a disparity; 
however, access to proper health care was listed as a strong 
contributor to the prevalence of this disparity. 



were: 



Two major areas of concern in health care access for minorities 

• The lack of certain types and numbers of services and programs. 

• Barriers to existing services. 

In addition, the need for generally improved access, quality, and 
utilization of services such as primary care, screening, detection, 
treatment, follow-up, and public (health) education programs were 
frequently cited. Current health services' research and promotion were 
pinpointed as inappropriate or inadequate for identifying, 
communicating with, convening, and involving minorities through 
community-based groups, such as: schools, churches. Health 
Maintenance Organizations (HMOs), worksites, and voluntary health 
groups. In addition, the paucity of screening and health education 
programs was identified as a leading cause of delayed diagnosis and 
the poor prognosis for medical problems. 

Specific problems of access to health care included: 

• Lack of health care for mothers and children. 

• Lack of access to services for early detection of diseases such 
as cancer, hypertension, and diabetes and other specialty health 
care. 

• Inability of non-English speaking people to use freely the health 
care system because of language and cultural barriers. 

• Less access to, and inappropriate use of, health services. 

• Poor quality of health care. 

• Underutilization of existing health resources because of a lack 
of knowledge and motivation. 

• Lack of physicians in rural areas. 



207 



• Problems with health care facilities, including af fordability, 
location, hours of operation, and transportation to and from 
the facilities. 

The major theme of these responses pointed to a need for more 
health education programs tailored to the minority group being served, 
on the following issues: prenatal and infant care, proper nutrition 
and weight reduction, management of chronic illnesses, family planning 
and sex education, and alcohol and drug abuse counseling. Respondents 
often stressed the need for programs that emphasize preventing disease 
and promoting good health and good health practices. 

Chronic Diseases 

Hypertension (high blood pressure), cardiovascular disease, 
cerebrovascular disease, cancer, and diabetes were most often cited as 
specific diseases that contribute to the health disparity. Most 
respondents believed that, if adequate screening programs were available and 
utilized, more chronic diseases experienced by minorities could 
be detected early. Respondents also believed that effective patient 
education and follow-up programs would help to reduce illness and death. 

Pregnancy and Birth Disorders 

Pregnancy-related concerns such as infant mortality, low 
birthweight infants, and prenatal, perinatal, and postnatal care were 
cited by many respondents as major issues. 

Access to proper health care was again cited. In the view of 
most respondents, early and adequate prenatal care and counseling is 
unavailable or underutilized among minority populations. Also, access 
to high technology techniques was seen as inadequate, creating a 
higher incidence of complications of pregnancy and birth. 

Many factors that contribute to pregnancy and birth disorders were 
believed to be manageable with proper access to appropriate, adequate, 
and early care. Such care includes regular prenatal checkups, 
nutrition counseling, management of any chronic health problems, and 
postnatal care for infants and mothers. Access to family planning 
services was often mentioned as potentially helpful in reducing low 
birthweight and infant mortality. 

Availability of Data 

Inadequacy of data on minorities was cited as a major barrier to 
developing effective health care strategies and programs. The lack of 
data for Hispanics and Asian/Pacific Islanders was cited most often. 



208 



other Disparities 

Respondents noted a number of other areas of disparity: 

• Homicide, suicide, and unintentional injuries; alcohol and drug 
abuse; and problems related to stress. 

• Inadequate education. 

• Poor nutrition. 

• Underrepresentation of minorities in the health professions. 

• Problems related to environment, such as housing and unsanitary 
living conditions. 

• Discrimination, deterioration of the family structure, lack of 
support services and recreational facilities, and low self-esteem. 

The quality of education that many minorities receive and their 
lower educational attainment have a substantial impact on their 
socioeconomic status, in the opinion of respondents. Educational 
deficits were believed to be caused by such factors as insufficient 
parental guidance, lack of encouragement to achieve, and lack of 
emphasis on education in general. Low educational attainment is seen 
as both a result and a cause of low socioeconomic status . 

Poor nutrition was cited by respondents as affecting nearly every 
aspect of health, particularly in diseases such as diabetes and 
hypertension and in relation to pregnancy and birth. 

Too few minorities in health care professions was mentioned as 
contributing to the cultural insensitivity that is said to exist in 
many health care facilities. Factors cited for underrepresentation 
include a lack of educational opportunity and financial and political 
resources for training of minorities in health care professions. 

Environmental concerns expressed by respondents included inadequate 
housing, unsanitary and unsafe working and living conditions, exposure to 
hazardous chemicals and materials in the worksite and in homes, and the 
danger of lead poisoning in children. 

Elements of Successful Programs 

Highlighting specific examples known to your organization, 
what kinds of health programs in the minority community have 
been most successful? What has been the key element of that 
success? 

Certain common elements seemed to contribute to the success of many 
health programs described by the respondents. These key elements include: 



209 



• Community involvement and outreach. 

• Program focus on comprehensive services, including disease 
prevention and health promotion. 

• Program ability to improve minority access to health services. 

• Cultural sensitivity to the group being served. 

Examples of health programs that have been successful in minority 
communities included: community outreach; hypertension control; 
maternal and child health care; family planning; health education, 
promotion, and prevention; bicultural and bilingual health care; and 
Medicare and Medicaid. In general, improved access to medical care 
was cited as a key element of a program's success; however, success 
was by no means limited to this element alone. 

All groups representing Blacks, Hispanics, Native Americans, and 
Asian/Pacific Islanders addressed community-based health programs. 
They cited comprehensive health services, such as dental care, social 
services, public health education, outreach, and prevention programs, 
as essential components to community health programs. The key element 
of success for these programs was that they were accessible and 
affordable. Other elements of success for community health programs 
included cultural sensitivity, networking with other agencies in the 
community, and control of health programs by community boards. 

Hypertension Detection and Follow-up Programs and maternal and 
child health care programs were regarded as successfully demonstrating 
these qualities. 

All groups emphasized health education, promotion, and prevention 
programs as successes in minority communities, based on experience 
with planning and delivery of services. 

All groups cited Medicare and Medicaid as successful programs. 
Respondents attributed success to improved accessibility and 
availability of quality health care to the socioeconomically deprived. 
Financial assistance and Government funding were also perceived as 
increasing opportunities for minority employment in the health care 
field; otherwise, such employment may not have been possible. 

Suggestions for Action 

Within the confines of the current Department of Health and 
Human Services programs and policies, how might DHHS better 
address the disparity in health status of minority 
populations? 



210 



Respondents proposed a variety of specific ways that DHHS might 
better address disparities in health status of minority populations, 
including the following: 

• Continue to support or fund existing health programs that have 
been successful. 

• Improve data collection and interpretation of data regarding 
specific minority groups. 

• Direct resources to prevention activities for high-risk minority 
populations . 

• Increase funding for health education programs and research on 
health disparities. 

• Incorporate bicultural/bilingual services into health programs. 

• Network with private medical and social communities. 

• Develop public education programs and other programs encompassed 
by the 1990 Objectives for the Nation . 

• Increase minority participation in policy development, education, 
and training programs, thereby increasing equal opportunity for 
minorities . 

• Increase accessibility to quality health care. 

• Encourage third-party payers to include coverage for health 
promotion/disease prevention. 

All groups recommended that DHHS target programs to populations 
and geographic areas with the highest rates of mortality and 
morbidity. They placed particular emphasis on the need to provide 
adequate funding for health education, prevention, and research for 
poor and minority populations and to support minority health programs 
within the community. 

In addition, minority groups indicated that DHHS might address 
the health disparities of minority populations more effectively by 
making appropriate use of viable and successful community programs and 
institutions, including families, churches, schools, small businesses, 
and others . 

All minorities who responded to the survey endorsed minority 
participation in policy development. 



211 



APPENDIX 



DEPARTMENT OF HEALTH AND HUMAN SERVICES 
SECRETARY'S TASK FORCE ON BLACK AND MINORITY HEALTH 

MEMBERS 



Thomas E. Malone, Ph.D., Chairperson 

Deputy Director 

National Institutes of Health 

Wendy Baldwin, Ph.D. 

Chief, Demographic and Behavioral Sciences Branch 

National Institute of Child Health and Human Development 

Betty Lou Dotson, J.D. 

Director 

Office for Civil Rights 

Office of the Secretary 

Manning Feinleib, M.D., Dr.P.H. 

Director 

National Center for Health Statistics 

William T. Friedewald, M.D. 

Director, Division of Epidemiology and Clinical Applications 

National Heart, Lung, and Blood Institute 

Robert Graham, M.D. 

Assistant Surgeon General 

Administrator 

Health Resources and Services Administration 

M. Gene Handelsman 

Deputy Assistant Secretary 

Office of Human Development Services 

Jane E. Henney, M.D. 

Deputy Director 

National Cancer Institute 

Donald R. Hopkins, M.D. 

Deputy Director 

Centers for Disease Control 

Stephanie Lee-Miller 

Assistant Secretary for Public Affairs 

Office of the Secretary 



215 



Jaime Manzano (Served until August, 1984) 
Formerly, Deputy Assistant Secretary 
Office of Human Development Services 

J. Michael McGinnis, M.D. 

Assistant Surgeon General 

Deputy Assistant Secretary for Health 

Director, Office of Disease Prevention and Health Promotion 

Office of the Assistant Secretary for Health 

Mark Novitch, M.D. (Served until February, 1985) 
Formerly, Deputy Commissioner 
Food and Drug Administration 

Clarice D. Reid, M.D. 

National Coordinator, Sickle Cell Disease Program 

Chief, Sickle Cell Disease Branch 

National Heart, Lung, and Blood Institute 

Everett R. Rhoades , M.D. 

Director, Indian Health Service 

Health Resources and Services Administration 

William A. Robinson, M.D. , M.P.H. 

Deputy Director, Bureau of Health Professions 

Health Resources and Services Administration 

James L. Scott (Served until June, 1985) 
Formerly, Acting Deputy Administrator 
Health Care Financing Administration 

Robert L. Trachtenberg 

Deputy Administrator 

Alcohol, Drug Abuse, and Mental Health Administration 

T. Franklin Williams, M.D. 

Director 

National Institute on Aging 



216 



ALTERNATES 



Shirley P. Bagley, M.S. 

Assistant Director for Special Programs 

National Institute on Aging 

Claudia Baquet, M.D., M.P.H. 
Program Director, Minority Field Program 
Division of Cancer Prevention and Control 
National Cancer Institute 

Howard M. Bennett 

Associate Deputy Director, Office of Management and Policy 

Office for Civil Rights 

Office of the Secretary 

Cheryl Damberg, M.P.H. 

Research Fellow 

Office of Disease Prevention and Health Promotion 

Office of the Assistant Secretary for Health 

Mary Ann Danello, Ph.D. 

Special Assistant to the Commissioner for Science 

Food and Drug Administration 

Jacob J. Feldman, Ph.D. 

Associate Director for Analysis and 

Epidemiology 
National Center for Health Statistics 

Marilyn Gaston, M.D. 

Deputy Chief 

Sickle Cell Disease Branch 

National Heart, Lung, and Blood Institute 

George Hardy, M.D. 

Assistant Director/Washington 

Centers for Disease Control 

John H. Kelso 

Acting Administrator 

Health Resources and Services Administration 

James A. Kissko 

Special Assistant 

Office of Human Development Services 



217 



Robert C. Kreuzburg, M.D. 

Acting Associate Director, Office of Program Operations 

Indian Health Service 

Health Resources and Services Administration 

Barbara J. Lake 

Special Assistant to the Director 

Office for Civil Rights 

Office of the Secretary 

Patricia L. Mackey, J.D. 
Executive Assistant to the Director 
Office for Civil Rights 
Office of the Secretary 

Delores Parron, Ph.D. 

Associate Director for Special Populations 

Alcohol, Drug Abuse, and Mental Health Administration 

Gerald H. Payne, M.D. 

Chief, Prevention and Demonstration 

Research Branch 
Division of Epidemiology and Clinical Applications 
National Heart, Lung, and Blood Institute 

Caroline I . Renter 
Office of Public Affairs 
Office of the Secretary 

Clay Simpson, Jr. , Ph.D. 

Director, Division of Disadvantaged Assistance 

Bureau of Health Professions 

Health Resources and Services Administration 

Ronald J. Wylie 

Special Assistant to the Administrator 

Health Care Financing Administration 



218 



SUBCOMMITTEES OF THE SECRETARY'S TASK FORCE 
ON BLACK AND MINORITY HEALTH 

COORDINATING COMMITTEE 

Thomas E. Malone, Ph.D., Chairperson 

Deputy Director 

National Institutes of Health 

Eileen M. Collins 
Office of the Secretary 

Jane Delgado, Ph.D. 

Special Assistant on Minority Affairs 

Office of the Secretary 

Robert Graham, M.D. 

Assistant Surgeon General, Administrator 

Health Resources and Services Administration 

Donald R. Hopkins, M.D. 

Deputy Director 

Centers for Disease Control 

Stephanie Lee-Miller 

Assistant Secretary for Public Affairs 

Office of the Secretary 

Clarice D. Reid, M.D. 

National Coordinator, Sickle Cell Disease Program 

Chief, Sickle Cell Disease Branch, National Heart, Lung, and Blood Institute 

Caroline I. Reuter 
Office of Public Affairs 
Office of the Secretary 

James Scott 

Formerly, Acting Deputy Administrator 

Health Care Financing Administration 

Patti Birge Tyson 

Executive Assistant to the Secretary 

Office of the Secretary 

Ronald J. Wylie 

Special Assistant to the Administrator 

Health Care Financing Administration 

Staff Liaison: 

Katrina W. Johnson, Ph.D. 

Study Director, Secretary's Task Force on Black and Minority Health 



219 



SUBCOMMITTEE ON CANCER 



Jane Henney, M.D. , Chairperson 

Deputy Director 

National Cancer Institute 

Claudia Baquet, M.D., M.P.H. 
Program Director, Minority Field Program 
Division of Cancer Prevention and Control 
National Cancer Institute 

Cheryl Damberg, M.P.H. 

Research Fellow 

Office of Disease Prevention and Health Promotion 

Office of the Assistant Secretary for Health 

Peter Greenwald, M.D. 

Director, Division of Cancer Prevention and Control 

National Cancer Institute 

J. Michael McGinnis , M.D. 

Assistant Surgeon General 

Deputy Assistant Secretary for Health 

Director, Office of Disease Prevention and Health Promotion 

Office of the Assistant Secretary for Health 

Earl Pollack, Sc.D. 
Formerly, Chief, Biometry Branch 
Division of Cancer Prevention and Control 
National Cancer Institute 

William Robinson, M.D., M.P.H. 

Deputy Director, Bureau of Health Professions 

Health Resources and Services Administration 

T. Franklin Williams, M.D. 

Director 

National Institute on Aging 

Staff Liaison: 
Lemuel Clark, M.D. 



220 



SUBCOMMITTEE ON CARDIOVASCULAR AND CEREBROVASCULAR DISEASES 



William T. Friedewald, M.D. , Chairperson 

Director, Division of Epidemiology and Clinical Applications 

National Heart, Lung, and Blood Institute 

Shirley P. Bagley, M.S. 

Assistant Director for Special Programs 

National Institute on Aging 

Howard M. Bennett 

Associate Deputy Director, Office of Management and Policy 

Office for Civil Rights 

Allan L. Forbes, M.D. 

Director, Office of Nutrition and Food Sciences 

Food and Drug Administration 

Lynn A. Lars en, Ph.D. 

Associate Director for Program Development 

Division of Nutrition, Center for Food Safety and Applied Nutrition 

Food and Drug Administration 

Mark Novitch, M.D. 

Formerly, Deputy Commissioner 

Food and Drug Administration 

Paul A. Nutting, M.D. 

Director, Office of Primary Care Studies 

Health Resources and Services Administration 

Gerald H. Payne, M.D. 

Chief, Prevention and Demonstration Research Branch 

National Heart, Lung, and Blood Institute 

Daniel D. Savage, M.D. , Ph.D. 

Medical Officer 

National Center for Health Statistics 

Ronald J. Wylie 

Special Assistant to the Administrator 

Health Care Financing Administration 

T. Franklin Williams, M.D. 

Director 

National Institute on Aging 

Staff Liaison: 
Donald Buckner, Ed.D. 
Valerie Williams, M.P.A. 



221 



SUBCOMMITTEE ON CHEMICAL DEPENDENCY 



Mark Novitch, M.D., Chairperson 
Formerly, Deputy Commissioner 
Food and Drug Administration 

Mary Ann Danello, Ph.D., Acting Chairperson 
Special Assistant to the Commissioner for Science 
Food and Drug Administration 

Stuart L. Nightingale, M.D. 
Associate Commissioner 
Office of Health Affairs 
Food and Drug Administration 

Robert G. Niven, M.D. 

Director, National Institute on Alcohol and Alcohol Abuse 

Alcohol, Drug Abuse, and Mental Health Administration 

William Pollin, M.D. 

Director, National Institute on Drug Abuse 

Alcohol, Drug Abuse, and Mental Health Administration 

Everett Rhoades , M.D. 

Director, Indian Health Service 

Health Resources and Services Administration 

Robert Trachtenberg 

Deputy Administrator 

Alcohol, Drug Abuse, and Mental Health Administration 

Ronald J. Wylie 

Special Assistant to the Administator 

Health Care Financing Administration 

Staff Liaison: 

Frank Hamilton, M.D. , M.P.H. 



222 



SUBCOMMITTEE ON DATA DEVELOPMENT 



Robert Graham, M.D., Chairperson 

Assistant Surgeon General 

Administrator 

Health Resources and Services Administration 

Jane Delgado, Ph.D. 

Special Assistant on Minority Affairs 

Office of the Secretary 

Manning Feinleib, M.D., Dr.P.H. 

Director 

National Center for Health Statistics 

Donald Hopkins, M.D. 

Deputy Director 

Centers for Disease Control 

Stephanie Lee-Miller 

Assistant Secretary for Public Health 

Office of the Secretary 

J. Michael McGinnis , M.D. 

Assistant Surgeon General 

Deputy Assistant Secretary for Health 

Director, Office of Disease Prevention and Health Promotion 

Office of the Secretary 

William Robinson, M.D. , M.P.H. 

Deputy Director 

Bureau of Health Professions 

Health Resources and Services Administration 

Staff Liaison: 
Clifford Patrick, Ph.D. 



223 



SUBCOMMITTEE ON DIABETES 



T. Franklin Williams, M.D., Chairperson 

Director 

National Institute on Aging 

Shirley P. Bagley, M.S. 

Assistant Director for Special Programs 

National Institute on Aging 

Maureen Harris, Ph.D., M.P.H. 

Director, National Diabetes Data Group Program 
National Institute of Arthritis, Diabetes, and 
Digestive and Kidney Diseases 

Robert Kreuzburg, M.D. 

Acting Associate Director, Office of Program Operations 

Indian Health Service 

Health Resources and Services Administration 

Lois Lipsett, Ph.D. 
Chief, Special Programs Branch 
National Institute of Arthritis, Diabetes, 
Digestive and Kidney Diseases 

Everett Rhoades , M.D. 

Director, Indian Health Service 

Health Resources and Services Administration 

Alex Sabatini 

Senior Operations Research Analyst 

Office of Human Development Services 

Robert Silverman, M.D., Ph.D. 
Chief, Diabetes Programs Branch 
National Institute of Arthritis, Diabetes, and 
Digestive and Kidney Diseases 

Staff Liaison: 

Frank Hamilton, M.D., M.P.H. 



224 



SUBCOMMITTEE ON HOMICIDE, SUICIDE, AND UNINTENTIONAL INJURIES 



Robert Trachtenberg, Chairperson 

Deputy Administrator 

Alcohol, Drug Abuse, and Mental Health Administration 

Thomas L. Lai ley 

Deputy Chief, Center for Studies of Antisocial 

and Violent Behavior 
National Institute of Mental Health 

Stephanie Lee-Miller 

Assistant Secretary for Public Affairs 

Office of the Secretary 

Delores Parron, Ph.D. 

Associate Director for Special Populations 

Alcohol, Drug Abuse, and Mental Health Administration 

Clarice D. Reid, M.D. 

National Coordinator, Sickle Cell Disease Program 

Chief, Sickle Cell Disease Branch 

National Heart, Lung, and Blood Institute 

Mark L. Rosenberg, M.D., M.P.P. 
Chief, Violence Epidemiology Branch 
Centers for Disease Control 

Staff Liaison: 

Marta Sotomayor, Ph.D. 

Lionel Fernandez, Ph.D. 



225 



SUBCOMMITTEE ON INFANT MORTALITY AND LOW BIRTHWEIGHT 



Wendy Baldwin, Ph.D., Chairperson 

Chief, Demographic and Behavioral Sciences Branch 

National Institute of Child Health and Human Development 

Marilyn Gaston, M.D. 

Deputy Chief, Sickle Cell Disease Branch 

National Heart, Lung, and Blood Institute 

Carol Hogue, Ph.D., M.P.H. 

Chief, Pregnancy, and Epidemiology Branch 

Centers for Disease Control 

Vince Hutchins, M.D. 

Director, Division of Maternal and Child Health 

Health Resources and Services Administration 

Joel Kleinman, Ph.D. 

Director, Division of Analysis 

National Center for Health Statistics 

Staff Liaison: 
Herbert Nickens, M.D. 



226 



STAFF: SECRETARY'S TASK FORCE ON BLACK AND MINORITY HEALTH 



Katrina W. Johnson, Ph.D., Study Director 
Secretary s Task Force on Black and Minority Health 
National Heart, Lung, and Blood Institute 

Donald R. Buckner, Ed.D. 
National Library of Medicine 

Gail Jacoby 

National Institute of Arthritis, Diabetes, and Digestive 
and Kidney Diseases 

Clifford H. Patrick, Ph.D. 
Social Security Administration 

Marta Sotomayor, Ph.D. 

National Institute of Mental Health 

Support Staff 

Ruth Guerrero 

Health Resources and Services Administration 

Sandra N. Howard 

National Institutes of Health 

Ann B . Jones 

National Heart, Lung, and Blood Institute 

Tracey Palm 

National Institute on Aging 



Pro Tempore Staff 

Allan Cayous 

Indian Health Service - Portland Area 

J. David Chananie, Ph.D. 

U.S. Merit Systems Protection Board 

Lemuel B. Clark, M.D. 

National Institute of Mental Health 

Theodore 0. Cron 

Office of the Assistant Secretary for Health 



227 



Lionel Fernandez, Ph.D. 

Bureau of Health Professions 

Health Resources and Services Administration 

Frank A. Hamilton, M.D., M.P.H. 
Commissioned Personnel Operations Division 
Office of the Assistant Secretary for Health 

Jessie Hackes 

Office of the Assistant Secretary for Personnel Administration 

Office of the Secretary 

Robert F. Heil 

Health Resources and Services Administration 

Sonia Milligan 

National Library of Medicine 

Herbert Nickens , M.D. 

Center for Studies of the Mental Health of the Aging 

National Institute of Mental Health 

Amy B. Slonim, R.D., Ph.D. 

Office of the Assistant Secretary for Planning and Evaluation 

Cleve W. Taylor 

Division of Management Policy 

National Institutes of Health 

Fu Sing Temple 

National Institute of General Medical Services 

Valerie N. Williams, M.P.A. 

Office of Health Planning and Evaluation 

Office of the Assistant Secretary for Health 

Louise H. Yates 

Health Resources and Services Administration 

Pro Tempore Support Staff 

Joselyn Monroe 

Division of Administrative Services 

National Institutes of Health 

Zoraida Villadiego 

National Institutes of Health 



228 



PAPERS COMMISSIONED BY THE TASK FORCE ON BLACK AND MINORITY 
HEALTH 



Relationship of Social Class to Coronary Disease Risk Factors in 
Blacks: Implications of Social Mobility for Risk Factor Change 

Lucile L. Adams, Ph.D., Epidemiologist, University of Pittsburgh, 
Pittsburgh, Pennsylvania 

Lewis H. Kuller, M.D. , Professor and Chairman, Department of 
Epidemiology, Graduate School of Public Health, University of 
Pittsburgh, Pittsburgh, Pennsylvania 

Ronald E. LaPorte, Ph.D., Associate Professor of Epidemiology, 
Department of Epidemiology, Graduate School of Public Health, 
University of Pittsburgh, Pittsburgh, Pittsburgh, Pennsylvania 

Laurence 0. Watkins , M.D. , M.P.H., Assistant Professor of Medicine, 
Section of Cardiology, Department of Medicine, Medical College of 
Georgia, Augusta, Georgia. 



Tapping the Black Communities' Endemic Alcohol/Drug Abuse Prevention 
Resources 

Mary Benjamin, Ph.D. , Director, Interdisciplinary Alcohol/Drug 
Studies Center, Jackson State University, Jackson, Mississippi 

Betty W. Fletcher, M.S.W., Associate Director, Research Training, 
Interdisciplinary Alcohol/Drug Studies Center, Jackson State 
University, Jackson, Mississippi 



Excess and Deficit Mortality Due to Selected Causes of Death and 
Their Contribution to Differences in Life Expectancy of Spanish- 
Surnamed and other White Males--1970 and 1980 

Benjamin S. Bradshaw, Ph.D., Associate Professor of Demography, 
University of Texas Health Science Center at Houston, School of 
Public Health, Houston, Texas 

W. Parker Frisbie, University of Texas at Austin, Population 
Research Center, Austin, Texas 

Clayton W. Eifler, University of Texas at Austin, Population 
Research Center, Austin, Texas 



229 



Patterns and Problems of Drinking Among U.S. Hispanics 

Raul Caetano, Ph.D., Scientist, Alcohol Research Group, 

Medical Research Institute of San Francisco, Berkeley, California 



The Effective Approach and Managment of Diabetes in Black and other 
Minority Groups 

John Davidson, M.D., Ph.D., Director, Diabetic Clinic, Grady 
Memorial Hospital, Atlanta, Georgia 



Increased Prevalence of Diabetes Among Japanese Americans and the 
Role of Environmental Factors in Its Genesis 

Wilfred Fujimoto, M.D. , Professor, School of Medicine, Metabolism, 
Endocrinology, and Nutrition, Universiity of Washington, Seattle, 
Washington 

Socioeconomic Position and Minority Health: A Summary of the Evidence 

Mary Haan, M.P.H., Research Scientist, Berkeley, California 

George Kaplan, Ph.D., Director of Human Population Laboratory, 
California Department of Health Services, Berkeley, California 

Family Violence and Homicide in the Black Community--Are They Linked? 

Robert L. Hampton, Ph.D., Associate Professor of Sociology, 
Connecticut College, New London, Connecticut 

Longitudinal-Situational Approaches to Understanding Black-on-Black 
Homicide 

Darnell Hawkins, Ph.D., J.D., Associate Professor of Sociology, 
University of North Carolina, Chapel Hill, North Carolina 



Associations of Health Problems with Ethnic Groups as Reflected in 
Ambulatory Care Visits 

M. Alfred Haynes , M.D. , President/Dean, Charles R. Drew 
Postgraduate Medical School, Los Angeles, California 



230 



Differences in Socioeconomic Status and Acculturation Among Mexican 
Americans and Risk of Cardiovascular Disease 

Helen P. Hazuda, Ph.D., Assistant Professor, University of Texas 
Health Science Center, San Antonio, Texas 



Prevalence and Incidence of Ischemic Heart Disease in United States' 
Black and White Populations 

Melford James Henderson, M.A. , M.P.H., Association of Black 
Cardiologists, Cardiovascular Research Fellow, Bethesda, Maryland 



Research Needs: Prevention and Intervention Strategies 

Leo Hendricks, Ph.D., Associate Professor and Director of Research, 
Institute of Urban Affairs and Research, Howard University, 
Washington, D.C. 



Expression of Diabetes Mellitus in Black Americans: Genetic, 
Epidemiological, and Therapeutic Aspects 

W. Lester Henry, Jr., M.D., Professor of Medicine, Howard 
University, Washington D.C. 

Juanita A. ArcI'L^r, M.D. , Associate Professor of Medicine, Howard 
University, Was' ■ip.-,ton, D.C. 



A Review of Drinking Patterns and Alcohol Problems Among U.S. Blacks 

Denise Herd, M.A. , Scientist, Alcohol Research Group, Epidemiology 
and Behavioral Medicine, Medical Research Institute of San 
Francisco, Berkeley, California 

Comprehensive Model to Detect, Assess, and Treat Effects of Assaultive 
Violence in Hospital Populations 

Karil Klingbeil, M.S.W., Director, Social Work Department, 
Assistant Professor of Social Work, University of Washington, 
Harborview Medical Center, Seattle, Washington 



Stroke Report 

Lewis H. Kuller, M.D., Professor and Chairman, Department of 
Epidemiology, Graduate School of Public Health, University of 
Pittsburgh, Pennsylvania 



231 



• 



Nutritional Status and Dietary Patterns of Racial Minorities in the 
United States 

Shiriki K. Kumanyika, Ph.D., M.P.H., Assistant Professor, Department 
of Epidemiology, Johns Hopkins University, School of Hygiene and 
Public Health, Baltimore, Maryland 

Deborah L. Helitzer, Doctoral Candidate, Department of 
International Health, Johns Hopkins University, Baltimore, Maryland 



Ischemic Heart Disease Risk Factors in Black Americans 

Ischemic Heart Disease Risk Factors in Hispanic Americans 

Ischemic Heart Disease Risk Factors in American Indians and Alaska 
Natives 

Ischemic Heart Disease Risk Factors in Asian/Pacific Islanders 

Shiriki K. Kumanyika, Ph.D., M.P.H., Assistant Professor, Department 
of Epidemiology, Johns Hopkins University, School of Hygiene and 
Public Health, Baltimore, Maryland 

Changes in the Criminal Homicide Rate of American Indians for the 
City of Los Angeles: 1970-79 

The Relative Risks of Types of Homicide Among Anglo, Hispanic, Black, 
and Asian Victims in Los Angeles: 1970-79 

Fred Loya, Ph.D., University of California, Los Angeles, The 
Neuropsychiatric Institute, Los Angeles, California 

The Black Female Criminal Homicide Offender in the United States 

Cora Mann, Ph.D., Associate Professor, School of Criminology, 
Florida State Univeristy, Tallahassee, Florida 



Analyses Commissioned by The Task Force on Black and Minority Health: 
Excess Deaths 1979-81, Excess Deaths 1969-71, Health Interview Survey, 
Excess Deaths in Hispanic Populations, 1979-81, Person-Years of 
Life Lost, Life Expectancy by Cause of Death 

Kenneth G. Manton, Ph.D., Research Professor of Demographic 
Studies, Duke University, Durham, North Carolina 



232 



Violence, an Epidemic; A Possible Approach: Neighborhood-Based, 
Interdisciplinary, Comprehensive Health Care 

Robert McGovern, M.D., Professor of Pediatrics, Director, Division 
of Ambulatory Pediatrics, Southwestern Medical School, The 
University of Texas Health Science Center at Dallas, Dallas, Texas 



Evaluation of Interventions to Reduce Racial Disparities in Infant 
Mortality 

Health Insurance Coverage of Perinatal Care for Minority Women 

Review of Interventions to Reduce Racial Disparities in Infant 
Mortality 

Case Studies of Selected Interventions: Limitations and Recommendations 
for Improving Infant Mortality Intervention Data for Minorities 

Margaret McManus , M.P.H., Director, McManus Health Policy, Inc. 
Washington, D.C. 



Coronary Heart Disease in Black Populations: Current Research, 
Treatment, and Prevention Needs 

Hector F. Myers, Ph.D., Associate Professor of Psychology, 
University of Los Angeles, Scholar-In-Residence, Charles Drew 
Postgraduate Medical School, Los Angeles, California 



Interdisciplinary Interventions Applicable to Prevention of Interpersonal 
Violence and Homicide in Black Youth 

Deborah Prothrow-Stith, M.D. , Assistant Professor of Medicine, Boston 
Univeristy, Boston City Hospital, Boston, Massachusetts 

The Escalating Incidence of Homicide in the Nation's Black 
Communities--Can We Intervene? 

Harold Rose, Ph.D., Department of Urban Affairs, University of 
Wisconsin, Milwaukee, Wisconsin 



233 



Analysis of Research Data on Trends and Differentials in Infant 
Mortality and Low Birthweight for Black, White, Hispanic, Asian, and 
American Indian Populations 

Barbara Samuels, M.D. , Research Fellow, Department of Maternal and 
Child Health, University of North Carolina, Chapel Hill, North 
Carolina 



Survival of High-Risk Minority Infants in Los Angeles County 

Robert Schlegel, M.D. , M.P.H., Professor and Chair, Department 
of Pediatrics, King-Drew Medical Center, Palos Verdes Peninsula, 
California 



Racial Variations in Self-Assessed Health and Socioeconomic Status 
in the 1976 Survey of Income and Education (SIE) 

William Serow, Ph.D., Professor of Economics, Florida State 
University, Tallahassee, Florida 

David Sly, Ph.D., Professor of Sociology, Florida State University, 
Tallahassee, Florida 



Minority Dental Health Manpower and Trends 

Jeanne Sinkford, D.D.S., Ph.D., Dean and Professor, College of 
Dentistry, Howard University, Washington, D.C. 



Factors Relating to the Increased Prevalence of Diabetes in Hispanic 
Americans 

Michael Stern, M.D. , Professor of Medicine, University of Texas 
Health Science Center, San Antonio, Texas 



Interviewing Persons Hospitalized with interpersonal Violence-Related 
Injuries: A Pilot Study 

Burnet Sumner, Ph.D. , Assistant Clinical Professor, Department of 
Surgery, University of California at San Francisco, San Francisco, 
California 



234 



Health Care Service Delivery in Asian American Communities 

Reiko True, Ph.D., Deputy Director, City and Council of San 
Francisco Community Mental Health Services, San Francisco, 
California 



Gang Homicide in Los Angeles 

Luis A. Vargas, Ph.D., Clinical Psychologist, Children's Psychiatric 
Hospital, University of New Mexico, Albuquerque, New Mexico 



Bibliography of Prematurity, Low Birthweight, and Infant Mortality 

Analyses of Scientific Articles of Prematurity, Low Birthweight, 
and Infant Mortality 

Adrianna Wesley, Consultant, Centers for Disease Control, Atlanta, 
Georgia 



Behavioral Weight Control for Obese Patients with Type II Diabetes 

Rena Wing, Ph.D., Associate Professor of Psychiatry, Western 
Psychiatry Clinical Institute, Pittsburgh, Pennsylvania 



Asian-White Mortality Differences: Are there Excess Deaths? 

Elena S. H. Yu, Ph.D., Associate Professor of Sociology 

in Psychiatry, Pacific/Asian American Mental Health Research 

Center, University of Illinois at Chicago, Chicago, Illinois 

Ching-Fu Chang, M.S., Graduate Research Assistant, Department of 
Sociology, Pacific/Asian American Mental Health Research Center, 
University of Illinois at Chicago, Chicago, Illinois 

William T. Liu, Ph.D., Professor of Sociology and Director, Pacific/ 
Asian American Mental Health Research Center, University of Illinois 
at Chicago, Chicago, Illinois 

Stephen H. Kan, Ph.D., Research Associate, Pacific/Asian American 
Mental Health Research Center, University of Illinois at Chicago, 
Chicago, Illinois 



235 



Physical and Mental Health Status Indicators for Asian/Pacific Americans 

Elena S. H. Yu, Ph.D., Associate Professor of Sociology in 
Psychiatry, Pacific/Asian American Mental Health Research 
Center, University of Illinois at Chicago, Chicago, Illinois 

William T. Liu, Ph.D., Professor of Sociology and Director, Pacific/ 
Asian American Mental Health Research Center, University of Illinois 
at Chicago, Chicago, Illinois 

Paul Kurzeja, M.A. , Graduate Research Assistant, Pacific/Asian American 
Mental Health Research Center, University of Illinois at Chicago, 
Chicago, Illinois 



236 



ACKNOWLEDGMENTS 



Numerous individuals assisted the Task Force on Black and 
Minority Health and greatly enriched its efforts. They delivered 
presentations, contributed information, assisted the Subcommittees, 
and provided data bearing on the complex social and scientific issues 
that were being explored by the Task Force. They were generous with 
their time and thoughtful in sharing their perspectives on the diverse 
problems that were under consideration. The Task Force wishes to 
express its grateful thanks to the following persons: 



Edgar Adams 

Sylvia T. Aguirre 

Loran Archer 

Remy Aronoff 

Michael Backenheimer , Ph.D. 

Marianne Balin 

Linda E. Bass 

Sam Bell, M.D. 

Marge Betts 

Ann Blank en 

William Blot, Ph.D. 

Ben Bradshaw, Ph.D. 

Donna Breslyn 

James Buechler, M.D. 

James Carlos 

Ronald H. Carlson 

Vivian Chang, M.D. 

Vivian Chen 

James Chin, M.D. 

Edward Chow, M.D. 

Effie Chow, Ph.D., R.N. , C.A. 

C.S. Chung, Ph.D. 

Roger B. Cole 

Beverly Coleman-Miller, M.D. 

Clark Collins 

John Cooper II, Ph.D. 

Blake C. Crawford 

Gregory Curt, M.D. 

Charles Darby 

William A. Darity, Ph.D. 

Fred Deer 

Tinamarie Dixon 

Vernon Dixon, M.D. 

Pamela Dobson 

Leonard A. Drabek 

Thomas Drury, Ph.D. 

Susan Eddins 



Frances C. Edmonds, Ph.D. 

Winston Edwards 

Frank E. Ellis, M.D. 

Marcia R. Feinleib 

Lorraine Ferguson 

Ed Fernandez 

Phyllis Flatery 

John Florez 

William Foege, M.D. 

Jane Lin-Fu, M.D. 

Vivian Garrison, Ph.D. 

George Gay 

Aida Giachello 

Richard F. Gillum, M.D. 

Joseph Gfroerer 

Dorothy Gohdes , M.D. 

Patricia M. Golden 

Marta Gonzalez 

Frederick K. Goodwin, M.D. 

Aaron Handler 

M. Alfred Haynes , M.D. 

Suzanne Haynes, Ph.D. 

Brenda Hewitt 

Robert Hoover, M.D. 

Bettie Hudson 

Deborah A. Hunter 

Suzanne Hurd, Ph.D. 

Aeolian Jackson, D.S.W. 

Jerome Jaffee, M.D. 

Earl Johnson 

Elaine M. Johnson 

Wilbert Jordan, M.D. 

JoAnn Kauffman, M.P.H. 

Samuel W. Kessel, M.D. 

Brian Kimes, Ph.D. 

Patricia Knapp 

Marilyn Kunzweiler, M.P.H. 



237 



Timothy Larkin 

William Lassek, M.D. 

Harry Lee, M.D. 

Joseph Levitt 

Helen Lin 

Francine Little 

William T. Liu, Ph.D. 

Janice Louie 

Diana Makuc, Ph.D. 

Ann C. Maney, Ph.D. 

Dorothy H. Mann 

James Marks, M.D. 

Russell Mason 

Nampeo McKenney 

Michael McMullan 

Arnold Mills 

J. Henry Montes 

Edward J. Montminy, M.D. 

John H. Moore, Ph.D. 

Hal ley Morgan, M.D. 

Marcella Murphy 

Robert Murphy 

Melvin Myers 

Audrea Nora, M.D. 

John Nut ley 

Vincent Oliverio, Ph.D. 

Virginia Ono 

Joan Weibel-Orlando, Ph.D. 

Charlene Ortiz, M.D. 

Kathy Owens 

Yuko Palesch 

Albert Pawlowski, Ph.D. 

Nancy Pearce 

David Pearl, Ph.D. 

Robert C. Peterson 

Mitchell B. Pierre, Jr. 

Elisabeth Pitt, M.A. 

Kate Prager, Ph.D. 

Amelie G. Ramirez 

George A. Reich, M.D. 

Diane Resnikov 

Y.B. Rhee, M.D. 

Knut Ringen, Dr.P.H. 



Norma R. Rivera 

Roger Rochat, M.D. 

Harry Rosenberg, Ph.D. 

Ruben G . Rumbaut 

David Satcher, M.D. 

Lynne Schneider 

Clarissa Scott, Ph.D. 

Don Shopland 

A. Logan Slagle 

Betsy Slay 

Richard J. Smith III 

Matthew Snipp, Ph.D. 

Ernell Spratley 

Howard V. Stambler 

Deborah B. Prothrow-Stith, M.D. 

Louis Sullivan, M.D. 

Leonora Surosky 

Carol Sussman 

Leonard Syme, Ph.D. 

Caroline Taplin 

Stephen P. Teret , J.D. 

James Thompson, M.D., M.P.H. 

Mary Thorngreen 

Diana Torres 

Fernando Trevino, Ph.D. 

Robert Trotter, Ph.D. 

Henrietta Villaescusa 

Sylvia Villarreal, M.D. 

Mary Virts 

Tom Voskuhl 

Monica Walters 

Ed Watkins 

Laurence 0. Watkins, M.D., M.P.H. 

Hazel Weidman, Ph.D. 

Sheridan Weinstein, M.D. 

Nola Whitfield 

Stacey L. Williams 

Jerome Wilson 

Ronald W. Wilson 

Kathryn Wimsatt 

Diane Wysowski, Ph.D. 

John Young, Ph.D. 



238 



KEY TO ABBREVIATIONS 



ADAMHA Alcohol, Drug Abuse and Mental Health Administration 

CDC Centers for Disease Control 

COSSMHO National Coalition of Hispanic Mental Health and Human 

Services Organizations 

DHHS Department of Health and Human Services 

FDA Food and Drug Administration 

HANES Health and Nutrition Examination Survey 

HCFA Health Care Financing Administration 

HRSA Health Resources and Services Administration 

IHS Indian Health Service 

LULAC League of United Latin American Citizens 

NAACP National Association for the Advancement of Colored People 

NCHS National Center for Health Statistics 

NCHSR National Center for Health Services Research 

NIH National Institutes of Health 

NIAAA National Institute on Alcohol Abuse and Alcoholism 

NIDA National Institute on Drug Abuse 

NIMH National Institute of Mental Health 

CASH Office of the Assistant Secretary for Health 

ODPHP Office of Disease Prevention and Health Promotion 

OHDS Office of Human Development Services 

0MB Executive Office of the President/Office of Management 

and Budget 

OS Office of the Secretary 

PHS Public Health Service 

SSA Social Security Administration 



239 



li U-S. GOVERNMENT PRINTINQ OFFICE: 



1989 - 211-280 - 814/05306 



DEPARTMENT OF 
HEALTH AND HUMAN SERVICES 

WASHINGTON, D.C. 20201 



OFFICIAL BUSINESS 
PENALTY FOR PRIVATE USE, $300 



POSTAGE AND FEES PAID 

U.S. DEPARTMENT OF H.H.S. 

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